Abstract

Informal payments for healthcare are widespread in sub-Saharan Africa. They are often regressive, potentially limiting access to quality healthcare, particularly for the most vulnerable, and can have catastrophic consequences for households. Yet there is little empirical research that uses theory-driven hypotheses to explore what influences informal payments and, especially, from health workers’ perspectives. Consequently, we have explored the characteristics of health workers and facilities influencing informal payments in Tanzania, examining two hypotheses: health workers with power and position in the system are more likely to receive informal payments, and transparency and accountability measures can be bypassed by those who can game the system. We conducted a cross-sectional survey of 432 health workers from 42 public health facilities (hospitals and health centres) in 12 district councils from Pwani and Dar es Salam regions in Tanzania. Our dependent variable was whether the health worker has ever asked for or been given informal payments or bribes, while explanatory variables were measured at the individual and facility level. Given the hierarchical structure of the data, we used a multilevel mixed-effect logistic regression to explore the determinants. Twenty-seven percent of 432 health workers ever engaged in informal payment. This was more common amongst younger (<35 years) health workers and those higher in the hierarchy (specialists and heads of departments). Those receiving entitlements and benefits in a timely manner and who were subject to continued supervision were significantly less likely to receive informal payments. The likelihood of engaging in informal payments varied among health workers, consistent with our first hypothesis, but evidence on the second hypothesis remains mixed. Thus, policy responses should address both individual and system-level factors, including ensuring adequate and progressive health sector financing, better and timely remuneration of frontline public health providers, and enhanced governance and supervision.

Highlights

  • Out-of-pocket payments (OOPs) for health care are a barrier to achieving Universal Health Coverage (WHO, 2010) but remain widespread in many low- and middle-income countries (LMICs), despite being inequitable, often regressive, and inefficient as a financing mechanism (Asante et al, 2016)

  • We examine characteristics of health workers and health facilities associated with informal payments in Tanzania, where they are common and take many forms (Kruk et al, 2008; Stringhini et al, 2009; Mæstad and Mwisongo, 2011; Lindkvist, 2013)

  • We found that 27% out of 432 health workers engaged in informal payment, and the practice was common especially amongst younger (

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Summary

Introduction

Out-of-pocket payments (OOPs) for health care are a barrier to achieving Universal Health Coverage (WHO, 2010) but remain widespread in many low- and middle-income countries (LMICs), despite being inequitable, often regressive, and inefficient as a financing mechanism (Asante et al, 2016). They can create barriers to care (Ensor and Cooper, 2004; O’Donnell, 2007), increasing the risk of catastrophic expenditure (WHO, 2010) and undermining confidence in public institutions (Clausen et al, 2011; Habibov, 2016) They may respond to a dysfunctional system (Meon and Weill, 2010), overcoming inefficiencies or bureaucratic obstacles to service delivery (Leff, 1964; Gaal and McKee, 2004) or motivating providers to stay at their post, supplementing their low salaries (Gaal and McKee, 2004; Lewis, 2007; Mæstad and Mwisongo, 2011). Informal payments can represent cultural norms of gratitude (Smith, 2008; Truex, 2011; Lee and Guven, 2013), with material consequences only if they are large or frequent (Gaal et al, 2006a)

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