Abstract
BackgroundInformal payments in public health facilities act as a barrier to accessing quality health services, especially for poor people. This research aimed to investigate informal payments for health care services at Kamuzu Central Hospital (KCH), a public referral hospital in Malawi. Results of this study provide evidence on the prevalence and influencing factors of informal payments for health care so that relevant policies and strategies may be developed to address this problem.MethodsThis study employed a mixed methods research design. The quantitative study had a sample size of 295 patients and guardians. The qualitative study had 7 key informant interviews (with health workers, health managers and policy makers) and 3 focus group discussions (FGDs) with guardians. Each FGD included 10 participants. Thus, in total, the qualitative sample comprised 52 participants. Quantitative data was analyzed using Excel and STATA. Qualitative data was analyzed using a thematic content analysis approach.Results80% of patients and guardians had knowledge of informal payments. Approximately 47% of respondents admitted making informal payments to access health services, and 87% of informal payments were made at the request of a health worker. Lack of knowledge, fear and desperation among patients and guardians, low salaries of health workers, and lack of effective disciplinary measures, were reported as key factors influencing informal payments. Regression analysis results showed that occupation and gender were the main determinants of informal payments.ConclusionsInformal payments exacerbate inequality in access to free public health services. Particularly, poor people have limited access to health services when informal payments are demanded. This practice is unethical and infringes on people’s rights to universal access to health care. There is a need to strengthen the public health care system by formulating deliberate policies that will deter informal payments in Malawi.
Highlights
Informal payments in public health facilities act as a barrier to accessing quality health services, espe‐ cially for poor people
These “under-the-table” payments motivate health workers and can influence physicians regarding which health care services to provide to which patients [9]
This study aimed to investigate informal payments for health care in Malawi to determine the prevalence of the practice, the factors that influence it, the services that are associated with informal payments and the challenges that guardians and patients as well as the health system face as a result of informal payments
Summary
Informal payments in public health facilities act as a barrier to accessing quality health services, espe‐ cially for poor people. Results of this study provide evidence on the prevalence and influencing factors of informal payments for health care so that relevant policies and strategies may be developed to address this problem. There is growing evidence that many low-income countries have limited access to quality health care services due to demands for payments for services that should not be paid for [7]. The challenge with informal payments is that they are shrouded in secrecy and are difficult to document [8] These “under-the-table” payments motivate health workers and can influence physicians regarding which health care services to provide to which patients [9]. Informal payments in public hospitals are seen by most as morally undesirable and unethical [4], and they can result in low-quality service in terms of time and services [6]. Some authors have suggested that poor working conditions and sociocultural environments force health workers to accept informal payments [11]
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