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

Background: 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. Methods: 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. Results: 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. Conclusion: 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.


Background
In recent years, there has been an increasing trend in outof-pocket payments in Iran. This can be explained in part by inflation, technological advancement and epidemiological transitions, but it is also due to an increase in the practice of informal charges being demanded by physicians (1). Informal payments; the money paid to doctors for services outside of the framework of formal tariffs (2), or charges which patients pay in addition to the formal tariffs, are a widespread phenomenon (1). These payments are one of the many coping strategies adopted by medical staff and patients, in countries where health systems are underfunded, overstaffed, and burdened with broad mandates promising free access to care (3). Informal payments in the health sector are becoming an increasingly urgent and debated issue, especially in developing and transitional countries in Central and Eastern Europe (CEE); the Former Soviet Union (FSU); Central, Eastern and Southern Asia; Africa and South America (4). These wide spread phenomena have been estimated to constitute 10% to 45% of total out-of-pocket expenditure on healthcare in many low-income countries (2). Similar calculations for many other countries show that a lot of money that could save lives, prevent suffering and treat pain is currently being wasted due to excessive costs (5). In Poland, informal payments have been estimated to come to as much as twice the value of physicians' salaries (6); in Bangladesh, earnings from unofficial charges exceed official salaries by a factor of ten (7,8), and in Cambodia, by a factor of five (9). Evidence on the existence of informal payments has been reported in at least 22 studies (10), almost all of which concern lowincome countries (8).
While some patients give informal payments willingly, such as to express gratitude or expedite care, other patients feel compelled to make these 'unofficial' payments in order to obtain a higher quality of service or even any care at all (11). With patients paying informally to jump the queue, receive better service or more care, such payments have the potential to limit access to healthcare services to patients who have a greater ability to pay, rather than those with the greatest need (2). Informal payments can also cause people to forgo or delay care, sell assets in order to obtain care, and lose faith in the health system (12).
In addition to increasing health costs, these under-thetable payments also develop distrust among public to the medical professionals, and damage the doctor-patient relationship (1). They also jeopardize governments' attempts to improve equity and access to care, and policies targeted at helping the poor (2). It is well documented that informal patient payments are seen as a negative feature of health care provision due to their adverse effects on equity and the fact that they can hinder the determination of the future funding requirements of the health care sector (13)(14)(15)(16). Receiving under-the-table payments is illegal in some countries and can lead to prosecution by the police for example in Tanzania (8). In some countries, a special phone number can be used to report such behaviour (1). Some studies have shown that the quality of clinical care is affected by informal payments, for example family members giving injections to avoid paying nurses, and doctors recommending procedures that will increase their income rather than choosing them for their therapeutic benefit (3). Informal payments in government-run facilities also negatively impact health financing systems, draining revenue that is needed to support public sector goals and activities (17). Some researchers have also documented some positive aspects of informal payments including creating continuous relationships between patients and providers, improving staff morale, keeping health workers from leaving the public system, and allowing patients to show their respect to providers with whom they feel pleased (5). Although the importance of data on informal patient payments is universally recognized, there have been few attempts to study this phenomenon, especially in the context of Iran (1,18). This might be due to the challenges involved in data collection, given the informal and potentially sensitive nature of the topic (3,19,20). To fill this knowledge gap, this paper aimed to identify the motivations behind informal payments in Iran, how informal payments are perceived and why they are made in the health system of Iran from the perspectives of patients, health care providers and officials.
In what follows a brief sketch of the Iranian health system is provided before elaborating on the research methods. This will be followed by presenting the research results and a put forward the discussion and conclusion.

Health system in Iran
Ministry of Health and Medical Education (MOHME) is in charge of Iran's health system and all decisions for governance, policy making, planning and implementing the policies are centrally made by the MOHME. At the next level, medical universities are in charge of providing health services, supervising private sector, training medical sciences students, and conducting medical and health research in their catchment area. The Ministry of Labour and Social Affair (MoLSA) is another main stakeholder in Iran's health system with its role in financing health services specially at the secondary and tertiary levels. Although there is High Council of Medical Services Insurance (headed by the MOHME), which is the responsible entity for setting annual medical tariffs; the private sector does not apply the tariffs consistently. High Council of Medical Services Insurance enjoys members from both ministries (MOHME and MoLSA) and other stakeholders including medical council (21). Iran's health system has undergone a major reform in order to revolutionize health system, under this reform family physician plan has been launched in rural areas since 2005. This reform mainly seeks to strengthen referral system, to enhance health equity, and to break financial relation of physician and patient which might have some positive effects on informal payments (22).

Methods
We adopted a qualitative research stance in which we interviewed with consumers, providers and officials from public and private sectors, teaching and non-teaching facilities in Kerman province. We selected face-to-face semistructured interviews because individual interviews usually help the researches to investigate personal experiences of individuals in more depth (3). Face-to-face interviews are also considered the most suitable approach when aiming to gain an understanding of what respondents mean (23). Moreover, this made triangulation of the data possible through the participation of all parties (i.e. consumers, health care providers and officials).

Sampling
We applied the purposive method using the following criteria for each group: consumers (service utilization, willingness to participate), providers (related experience, willingness to participate, being actively engaged in service provision), and officials (related experience, willingness to participate). We also applied snowball sampling whenever necessary. We interviewed a purposive sample of 45 participants according to "the predefined criteria" (90% response rate) who were identified in consultation with a member of the Kerman Medical Council, two hospital executives, one former member of the council and the interviewees. The participants were invited through phone calls, followed by letters containing the research objectives and interview questions.
The 45 face-to-face interviews (comprising 30 patients [P], 12 providers [Pr] and 3 officials [Of]) were conducted in 2010, and were tape-recorded and transcribed. Each interview lasted between 10 and 50 minutes. Two of the authors of this paper (A.E and F.R) conducted all of the interviews. The interview questions were designed so that they captured the opinions and beliefs of the participants regarding different aspects of informal payments in Kerman province. In order to gain a better understanding of the context, the first two interviews were conducted in depth as a pilot. These helped us to prepare a suitable set of questions for the later semi-structured interviews. We had an interview guide which was almost the same for various groups of our participants; the first part of the interview for all groups contained questions on demographics. The patients were then questioned about whether they have paid informal payments, after explaining the definition of informal payment by the interviewers. The final section of the interview guide for all groups consisted of open-ended questions seeking why patients give informal payments to the providers and why the providers ask for them.

Ethical considerations
The participation in the study was voluntary, verbal consent was sought prior to the study and voices were recorded only if the participants agreed. Additionally, we removed parts of interviews in which there were some information which could lead to identification of third parties.

Data analysis
All interviews were transcribed into Farsi, while listening to the audio-tapes and concurrently checking against the notes taken during the interview. The transcriptions were then read through while listening to the audiotape, to ensure accuracy of transcription. All of these Farsi transcripts were then translated into English by the authors (M.A and A.E). However, some sections of the Farsi transcripts were translated separately by other authors, and some were back-translated to confirm linguistic consistency, and the precision of the translation to ensure credibility of translation. We analysed the data using content analysis.

Results
Interviewees' demographic characteristics are shown in Table 1. The data analysis yielded five main themes in relation to informal payments. These themes cover issues such as the reason for paying and asking informal payments, the services more susceptible for asking informal payments, the mechanism of asking such payments and the disadvantages associated with them, which are described in detail in the following sections:

i) Why informal payments are paid?
This section focuses on the reasons behind patients offering informal payments, either voluntarily or mandatorily. It reflects the views expressed in the interviews conducted with consumers. We classified these reasons under three main categories: cultural, quality-related and legal factors, which are elaborated on below.

Cultural factors
Several cultural aspects lead people to make informal payments, some of which can be attributed to broad cultural aspects with a long history that have been internalized in the day-to-day activities and lives of the people. Cultural factors behind informal payments include:

Expression of gratitude
The consumers believed that when someone does a good thing for you, you have to do your best for him/her. The consumers stated that they would provide informal payments as an expression of gratitude if the provider did not directly ask for: "I myself gave the physician a gold coin, because he didn't ask me" P3; "I will give a gift to the surgeon who performed the operation for my mother" P12; "if there is serious surgery and they save a patient's life, people feel they have to provide a gift to show their appreciation" P25.

Importance of health
The consumers regarded health as the most important asset any individual possesses. This is emphasized in Iran's tradition and culture, so that people are ready to pay money to maintain or restore their health: "You have to pay, after all there is nothing more important than health" P14; "it is not important how much (money) you have, when you are not healthy" P30.

Presence of an offering culture
In Iran, and especially in Kerman province, a phenomenon called an "offering culture" is prevalent in which people are reluctant to say no to requests, even if they know they are not legal. This is especially true of physicians' requests: "when the doctor asked me to pay extra, I could not say no to him, although I knew it was illegal" P1; "it is not moral to file a claim, just for monetary issues, against a doctor who has helped me" P10.

Lack of public awareness of their rights
Informal payments are often made because people are not aware of their rights and assume they have to pay any money the physician asks them for: "I thought it was part of the treatment charge" P16; "I did not think they were asking for extra" P11.

Quality-related factors
Besides cultural factors, several quality-related factors urge people to make informal payments. They often make informal payments to avoid being treated by students, to jump the queue, to receive customized services, or to be treated by a well-known physician: "I paid in order not to be operated by resident physicians " P2; "… the physician asked me to pay extra otherwise I would have had to wait some months" P28; "… I could be operated on by another surgeon, but I paid underthe-table to be operated on by this well-known surgeon" P6. Other consumers reported having a sense of fear or insecurity, which made them pay extra, for example: "I was afraid what would happen to my mother if I did not agree to pay extra" P8. Others wished to receive special attention from providers, with one patient claiming "I paid the nurse to provide better care for my daughter" P17.

Legal factors
We also noticed that there were some instances where the patients knew that they did not have to pay extra, but still paid because they believed both the law and the complaints process to be insufficient: "Since there is no efficient monitoring, we have got used to make such payments" P27; "physicians support each other and are integrated. I am not optimistic about the legal system" P13. Others said that they could not complain because they did not have any evidence: "I do not have any evidence to complain. Although I paid, I don't know how to prove it" P20. On the other hand, some patients did not complain because they were afraid of not receiving complete care if they did so: "I would like to complain, but if I do, he might not treat me" P21; "what if I need to go to his office again?" P18.

ii) Why informal payments are requested?
Our study revealed four set of factors behind providers asking for informal payments: these are tariff-related, structural, and moral factors as well as to show competence.

Tariff-related factors
The providers interviewed for this study claimed that the tariffs set by the Insurance Supreme Assembly are unrealistic, insufficient, inequitable and lack sufficient monitoring. They hold the view that they are underpaid and therefore have to complement their salaries with under-thetable payments: "official tariffs do not compensate our expenses" Pr10; "when I compare myself with other professions, I just don't feel I have been treated equitably" Pr4. Others claimed that the Assembly consciously sets unrealistic tariffs because of a lack of resources: "tariffs are set based on insurance funds not on real costs" Pr1.

Structural factors
Factors pertinent to the structure of health system can be categorized under structural factors. Factors such as laws, the direct patient-physician relationship, the health sector's low share of Gross Domestic Product (GDP), the presence of discrimination in the medical community, delays by insurance companies in paying charges, and an inappropriate insurance approach, can all be put into this category. One official stated "health's share of GDP is very low and there are not sufficient resources" Of1. Another official asserted "our insurance companies are just a median for money transition. No policy making or planning happens within them" Of2.
Although some participants took the view that the financing system paves the way for providers to ask for extra money: "the direct financial patient-physician relationship facilitates asking for informal payments" Pr7, others claimed that it is the interprofession discrimination [i.e. an increasing income gap between different groups of the medical profession] that cultivates an environment in which informal payments are asked for: "even in the medical profession, there is some discrimination that make physicians ask for informal payments" Pr6.

Moral factors
Some participants held the view that the underfunded health system, unrealistic tariffs and other factors were not reasonable excuses for charging patients extra informal fees, claiming that physicians should have professional morals. They suggested that morals are a strong factor prohibiting providers from asking for illegal payments: "morals are the strongest mechanism to control" Of3. Other participants also implied that the problem of informal payments originates from the dilution of professional morals: "professional morals have been diluted and money dominates everywhere" Of2; "some physicians have enough money to have a good living, they just want more" Pr2.

To show their competence
An interesting reason for asking for informal payments, mentioned by some of the participants, was the view that this will reinforce the perceived competence and quality of the physician's services. One official said "I know some physicians who ask for informal payments just to show patients that they are competent" Pr9. This was also highlighted in one of the interviews with the patients: "one tends to think the physician who doesn't ask for extra money isn't skillful, or might not look after patients very well" P3.

iii) How payments are made?
Because of the illegal nature of informal payments, we could not gain suitable insights from our interviews of providers and officials into how these payments are made, and therefore confined ourselves to investigating this issue in the consumer interviews. Several methods were mentioned, including cash payments and being given an account number into which the payment should be made. Most of the time, the physicians asked for informal payments indirectly: "the secretary asked me to make informal payments for a cesarean section" P7; "the surgeon introduced me to someone else who I had to pay" P19. Another participant declared "we needed our certificate to get signed; he didn't sign it in the public hospital and asked us to come to his office, where he signed it after being paid" P23.

iv) The services for which informal payments are made
Although informal payments are pervasive among several groups of providers, this study showed that they are particularly common in the case of complex or difficult services such as surgery, cardiovascular procedures, orthopedics and the like. One general physician claimed "general physicians don't take informal payments, but specialists, surgeons with a higher reputation ask for high informal payments" Pr12. Two of the patients interviewed made the following comments: "obstetricians ask for high informal payments for curettage" P26; "my uncle cut the tendons on his hands and the orthopedist asked him to pay extra on top of the hospital bill, to be operated on" P15.

v) The disadvantages of informal payments
In general, almost all the participants agreed that informal payments are not desirable; each group viewed the disadvantages from their own point of view. Generally speaking, their opinions can be categorized under three main categories: harm to the patient-physician relationship, harm to the performance of the health system and feeling guilty by providers.

Harm to the physician-patient relationship
The most likely effect of such payments is that they destroy patient-physician relationships. A decrease in patients' trust of physicians and destruction of the 'saintliness' of the medical profession were among the most important adverse effects mentioned: "this type of monetary patient-physician relationship is deteriorating public trust in physicians" Pr5. One patient expressed the view that asking for or receiving informal payments will not only develop patient distrust in that physician in particular, but will also have an adverse effect on the medical community as a whole: "… this way, the whole medical community will be implicated, although most of them have good intentions" P5.

Harm to the performance of the health system
Another adverse effect of informal payments is the harm they impose on the overall performance of the health system, through increasing out-of-pocket payments, possibly preventing some patients from using health services and even exposing some households to catastrophic healthcare expenditure. One of the interviewees asserted that informal payments destroy health system performance as they prevent funds from flowing into the health system: "these funds are received by individual physicians and, in practice, do not flow into the health system, so they are destructive rather than constructive" Of3.
Another issue is the long term consequences on the health system and society: "when people pay under-the-table payments, no money is left for food. In this way his/her children become ill due to malnutrition and this will start a vicious circle, which will impose heavy costs on the health system" Of2. These payments can also harm the health system by worsening health inequities, as expressed by one interviewee: "it is unfair to force someone who does not have any money to pay extra for the sake of his/her own or his/her family's health" Pr11.

Feeling guilty by providers
The interview account revealed that one of the unique disadvantages in Iran of such payments originates in the country's religious beliefs, which consider receiving such money to be forbidden (Haraam). The participants indicated that most physicians are unhappy about receiving such payments and some are concerned about their afterlife: "… one of disadvantages is the personal issues, since this money is not Halal" Of2; "if you ask any Ayatollah, they will say that since it is illegal it is religiously forbidden (Haraam) too" Of2.

Discussion
Our study indicates that informal payments are present in Iran's health system as in other countries. We have explored the phenomenon in the context of Iran's health system by involving three main stakeholders. Previous studies have reported that people make informal payments to express gratitude (3,24,25), to get additional or better services (3,26), or because of cultural norms ingrained in their tradition, and weak laws (25). This study indicates that all of the above mentioned factors affect patients' decisions to make such payments, although some of them seem to play a more important role. Some people might pay medical staff informally because they feel they should pay or because they have problems differentiating between formal and informal payments (11) but, according to our study, there are also some instances where people know they do not have to pay but still do so. As well as quality-related factors and a desire to jump the queue or express their gratitude, some agree to make informal payments because they believe the law is weak or because they are reluctant to ignore a request from their physician (known as the offering culture in Iran, and particularly evident in Kerman province) (27).
The literature suggests that underfunding of the health system (28) and insufficient official payments to providers (8) are the most important supply-side factors leading to informal payments. Our study not only confirms this but also reveals another interesting factor; we discovered that some physicians ask for extra money simply to create the idea among their patients that they are a high-quality practitioner. They are afraid that if they do not ask for extra money, they may lose their patients. However; this claim has still to be investigated, as to whether it is a leading factor behind asking for informal payments, or just one among many.
Under-the-table payments have important adverse effects for all the parties involved. For example, they can prevent patients from receiving care (5), distort the flow of funds within the health system (28), and increase inequalities in health (11). Even providers do not necessarily welcome them, as they are illegal, and can engender a sense of fear and guilt among those who receive them (1). The presence of an agreement regarding the disadvantages of such payments among the main stakeholders provides an opportunity to develop strategies and interventions to overcome this alarming phenomenon. These should focus on addressing the structural issues of the health system rather than preventing or punishing individual instances of informal payments (8).
In spite of widespread awareness of the disadvantaged of informal payments, such payments have not been diminished, although there has been some success. Any efforts designed to overcome the issue of informal payments will fail unless based on a systematic approach. We believe that any strategy aimed at decreasing informal payments must consider the whole picture or it will certainly fail. Iran's health system has some long standing financial problems, which are the result of the war imposed on it. During the years of war, defence was prioritized and all national resources were mobilized to defend the country. Since the war ended, the health sector has never been able to obtain its fair share from the public purse (21,29). As a result, the health sector has always been underfunded and payments to physicians and other health service providers are not realistic and do not compensate them appropriately for their efforts. As we have identified in this study, if the Iranian health system can increase its financial resources, we would be optimistic of seeing an end to the majority of informal payments. This could be complemented with other necessary actions, such as, refining the current attitudes and beliefs of the general public and providers regarding the perceived advantages of and reasons for requesting or making informal payments (specially cultural and social factors) and strengthening the monitoring system for providers to improve the accountability of public work.

Conclusion
This study suggests that Informal payments in Iran are a multifactorial phenomenon with different players who have their own share in it. Different factors such as moral, religious and legal issues are behind informal payments in Iran, which are asking serious efforts by the government to build future interventions to reduce these payments. 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.

Limitations
The most important limitation of the present study is the fact that because of the illegal nature of informal payments, we could not study all aspects of informal payments. Dabalen and Wane state that informal patient payments are a sensitive research topic due to their illegality in some countries. This implies that there may be difficulties in estimating their real scope and magnitude, and above all difficulties in determining the frequency of their occurrence (24).
Additionally, this study was carried out in Kerman province, located at south east of Iran, so this might not be a representative picture of informal payment status in Iran.