Pay (in an envelope or as a gift) for free healthcare!
Informal payment for medical care
S.V.SHISHKIN, Vice–Rector of the State University - Higher School of Economics, Professor, Doctor of Economics.
Published on the website "Remedium"A special mechanism for financing healthcare is informal payment for medical care.
Abroad, this concept is used in a fairly broad sense. The most well-known is the definition of informal payment given by M. Lewis (Lewis 2000: 1), as payment to medical institutions or individuals with money or services outside official channels or the acquisition of what the health care system itself should provide. A stricter definition is proposed in (Gaal et al., 2006: 276): informal payment is a direct payment that is made in addition to any officially established payments, in cash or in kind, by a patient or other persons acting on his behalf, to a provider of services to which patients are entitled. Informal payments include money directly transferred to a medical professional by a patient or other persons on his behalf or in his favor, gifts, services provided to medical workers and medical organizations, as well as patient expenses for the purchase of medicines and medical materials for outpatient or inpatient treatment and food expenses, if the current legislation provides that such expenses should be borne by the state and provide patients with medicines and food free of charge.
If we use these definitions, then in our country two types of payments should be considered as informal payment for medical care:
- payments in cash, gifts, services to medical workers for medical services and medicines;
- purchase of medicines and other medicines in retail for treatment in state and municipal hospitals.
Prevalence of informal payment practices for medical care abroadThe prevalence of informal payment practices depends on the level of socio-economic development of the country and cultural traditions.
Thus, they have almost no place in Western European countries, but are present in all post-socialist countries. At the same time, in Transcaucasia and Central Asia, the share of patients paying directly to doctors with gifts or money for their treatment exceeds 50%, and in Armenia it reaches 91%. In Central European countries, with the exception of Slovakia, this share has recently been no more than 20%. The lowest value of this indicator was recorded for the Czech Republic – 5%. This is directly related to the high level of public financing of health care in comparison with other countries under consideration. In terms of the prevalence of informal payments, Russia occupies an intermediate position between the countries of Central Europe, on the one hand, and the countries of Transcaucasia, Central Asia, Moldova and Ukraine, on the other.
It should be noted that in fact, in our country, informal payment is understood only as the first of the two above–mentioned types of payment - in the hands of medical workers (Shishkin et al., 2004: 15). It is in this narrower sense that the term informal payment for medical services will be used further in this work, unless it is specifically stipulated.
Estimates of the prevalence of informal payment practices for medical care in RussiaEstimates of the prevalence of informal payment practices obtained from various sociological studies vary markedly.
According to the largest National Survey of the Welfare and Participation of the Population in Social Programs (NOBUS), which was conducted in April-May 2003 with a sample of 44.5 thousand households, the share of households who paid informally for outpatient medical care during the 3 months preceding the survey was small - only 2%, and the share of households only 10% of those who paid into the hands of medical workers during hospitalization during the previous year (Besstremyannaya, Shishkin, 2005). Similar estimates are obtained according to the data of the Russian Monitoring of the Economic Situation and Health of the Population (RMEZ) with a sample of 4 thousand households: in 2004, 7 and 9%, respectively. Other studies give higher prevalence rates of informal payment. Thus, according to a survey conducted in June 2008 within the framework of the project "Consumer Sentiment Index in Russia" with a sample of 2.0 thousand respondents representing the opinion of the adult (over 16 years old) population of the country, the proportion of patients who paid informally for outpatient medical services reached 17%, and for inpatient treatment – 23%.
Lower ratings were obtained in a study by the Center for Strategic Studies of JSC Rosgosstrakh (2008). Among 6,222 respondents in 36 cities of Russia, about 13% said that over the past year they have paid for medical services directly to a doctor, bypassing the health care provider's cash register. In the previous year, this share was 14% of the number of those who decided on the answer.
From the point of view of the objectives of our research, the results of the survey of the target population – Internet users in 15 largest cities of Russia in December-January 2008 (sample size – 4865 respondents aged 18-58 years) are of particular interest (Rosbusinessconsulting, 2008). This group acts as "outperforming" in relation to the entire population, and the characteristics of its behavior can be used as a basis for predicting trends in applying for paid assistance for the entire population as the economy develops. According to the data obtained, 53% of respondents over the past year paid for medical services provided in state or departmental medical institutions directly to staff, and 7% paid only by hand, and 46% – both through the cashier and directly to medical workers.
Using data from various studies, it is very difficult to draw conclusions about the dynamics of the prevalence of informal payments. If we compare the results of monitoring surveys (RMEZ, IPN), then, according to RMEZ, the proportion of patients resorting to informal payment increased slightly in the period from 2001 to 2004, and according to IPN surveys, it has changed little over the past 2 years.
In recent years, there have been noticeable changes in the financing of healthcare. Government spending grew rapidly, the ability and willingness of the population to spend more on medical services increased. An unprecedented measure was the introduction of federal surcharges to primary care workers, which increased their earnings by about 2.5 times. Law enforcement agencies have stepped up the fight against doctors receiving money from patients. The impact of these factors has led to multidirectional changes in the practices of informal payments in different sectors of the system of providing medical care to the population.
According to a survey of doctors conducted in mid–2007 in the Saratov and Yaroslavl regions (621 respondents), the largest share of respondents - 45% are convinced that the practice of paying doctors in "envelopes" has expanded over the past 5 years, about 42% believe that it has remained the same, and only 11% of respondents noted it reduction.
Among those who believe that the practice of informal payments has decreased, more than half are therapists and pediatricians. And this, obviously, indicates a reduction in informal payments due to an increase in their remuneration to primary care workers within the framework of the national project "Health", implemented since 2006.
On the contrary, the prevalence of these practices among patients seeking specialized medical care (to narrow specialists in polyclinics and in hospitals) and the size of informal payments have increased. The reasons for this were:
- the increase in the claims of doctors to the level of real income, due to the general increase in living standards in the country, and the lag in wage growth from inflation, which doctors began to compensate by increasing the amount of payments received from patients;
- the selective increase in wages within the framework of the national project "Health" only to district therapists and pediatricians was perceived by other categories of doctors as unfair, and the growth of informal payments became a means of "restoring justice" in the ratio of wage levels of varying complexity;
- increasing the ability and willingness of the population to pay more for the services of medical personnel.
At the same time, some specialist doctors began to avoid receiving informal payments from patients for two main reasons:
- the risk of harassment by law enforcement agencies has increased;
- the possibilities of legal earnings have expanded (additional work in private clinics, the appearance of modern high-tech equipment used to provide paid services, participation in clinical trials of medicines, etc.).
The size of informal paymentsA detailed analysis of the size of informal payments is beyond the scope of this work.
We will limit ourselves to references to estimates given in other publications.
In November– December 2002, the Independent Institute of Social Policy together with the All-Russian Center for the Study of Public Opinion conducted a survey of 3,299 households in 2 subjects of the Russian Federation: Saratov and Yaroslavl regions, based on a sample representing their population. According to the data obtained, the share of payment for medical services by hand (including payment for the services of ambulance workers and the services of doctors and nurses at home) amounted to 42% of the amount of payment by households for medical services to the cash register of medical institutions (Shishkin et al., 2004).
According to the NOBUS study, the amount of informal payment for medical services in 2003 amounted to 20% of the amount of payment for medical care to the cashier.
According to the data of the Rosbusinessconsulting study (2008), on average, each respondent who used such services paid 6.5 thousand rubles through the cash register for receiving medical services in state or departmental medical institutions in 2007, and 2.7 thousand rubles outside the cash register, or 42%. It is interesting to note that the obtained ratio coincided with the above assessment of the NIS 5 years ago.
According to the expert assessment given in the publication of Business Statistics (2008), the shadow sector of the medical services market in the period from 2000 to 2008 increased from 25 to 107 billion rubles, and in 2010 it will reach 129 billion rubles. For comparison: according to Rosstat, the volume of paid medical services in 2007 amounted to 167.5 billion rubles.
According to the results of a study by the Center for Strategic Research of JSC Rosgosstrakh (2008), the average amount of informal payment for medical services in 2007 amounted to 620 rubles, and in the first half of 2008 increased 1.5 times, reaching 920 rubles.
Institutional models of informal payment for medical careInformal payment practices are characterized by a very pronounced institutional diversity.
In the study of the NISP (Shishkin et al., 2004), 4 types of informal payment models were identified: by tariff; by agreement; by request; as a thank-you. Quantitative estimates of the prevalence of these models were obtained based on population survey data. It turned out that informal payment for outpatient services is made mainly on the basis of established tariffs, and in the inpatient sector, gratitude payment is used somewhat more often than tariff payment.
According to the estimates of doctors obtained during a repeated study conducted in the same regions after 5 years, there were changes in the frequency of using various models of informal payments (Chernets et al., 2008). The prevalence of payment under the shadow tariff has increased, and such a variety of this model as payment under the so-called "conspiratorial" tariff has become actively used. In this case, the price of the service is not announced by the doctor in advance, but the patient learns about it from other patients. The frequency of using "payment on request" expressed during or after medical care has decreased.
There have been noticeable changes in the structure of doctors' positions in relation to NP over the past 5 years. The group of consistent supporters of such practices, which, according to our estimates, made up about a quarter of respondents 5 years ago, has now exceeded their third. In 2002, half of the interviewed doctors could be attributed to the group of forced supporters who took money from patients, but considered it a forced necessity. In 2007, the position of some of these doctors was transformed, and now a new separate group should be identified – risk minimizers. It can be attributed to about a quarter of the respondents who have clearly expressed motives for minimizing the risk associated with obtaining shadow income.
The group of "regretting doctors" who directly admitted that they would be willing to take money from patients, but for reasons beyond their control, patients do not pay them, has somewhat decreased (from about 15 to 10% of respondents). District therapists and district pediatricians dropped out of this group, who moved to the risk-minimizing group.
A clear distinction between informal payment practices using two evaluation categories has become common among doctors: extortion and gratitude. The criterion of differentiation is the voluntary payment on the part of the patient. The payment in the form of gratitude, made on the initiative of the patients themselves, is recognized by the overwhelming majority of doctors as a fully justified material compensation for the labor they spend. Extortion of money from patients, that is, receiving payment at the insistence of a doctor, is almost universally condemned.
These value judgments do not correlate, however, with the identified trends in the prevalence of various models of informal payments. The declared differentiation of assessments reflects the spontaneous legitimization of shadow payment practices in the minds of doctors rather than real changes in their attitude to different types of such practices. Over the past 5 years, doctors have clearly grown convinced that in the current situation, receiving informal payments is not only necessary, but humanly quite justified. The corporate norms existing among doctors, as before, support the practice of informal payment. Permission to receive payment‑gratitude from patients already acquires the character of a norm shared by most doctors.
The heads of medical institutions, who previously declared a position of forced resignation to the practice of informal payments, now do not hide their favorable attitude towards them, provided that they do not lead to public conflicts over extortion of money from patients.
Doctors also note an increase in the demands of patients on the quality of medical care paid by them informally. If earlier patients who paid the doctor in hand expected from him mainly additional attention for this, now they are increasingly demanding results, a certain quality of life after the treatment undertaken. In fact, at the initiative of patients, there is a change in the "shadow contract" concluded by them with doctors.
Summarizing the trends in the institutional dynamics of informal payment for medical care, it can be concluded that on the periphery of the space of such practices, their scale is decreasing under the influence of state policy (increased sanctions by law enforcement agencies and a significant but selective increase in salaries for doctors) and the development of a legal market for medical services, expanding alternative income opportunities.
On the contrary, in areas where informal payments are widespread (in the "nuclei of their crystallization"), their scales are growing, their institutional forms are developing (the widespread use of the payment model at a secret tariff) and their legitimization in the minds of doctors is increasing.
Informal payments continue, as in the 90s, to perform the function of compensating for the low wages of doctors by the state and keep the medical corps in the workplace. In recent years, a new positive function of informal payments has clearly manifested itself: they act as a strong incentive for the professional growth of doctors. The growing demands of patients on the quality and effectiveness of treatment and the desire of doctors to increase their income make them master new medical technologies, improve their professional skills in order to successfully compete for patients' money with their colleagues.
However, one should not overestimate the positive impact of informal payments on the Russian healthcare system as a whole. The doctors themselves testify that there is a decrease in the availability of high-quality medical care for the population who cannot resort to informal payments or official paid services.
Recommendations for public policyThe conducted research allows us to make the following recommendations for public policy regarding informal payment for medical care.
Setting the task of eradicating informal payment practices in the foreseeable future, even with realistic forecasts of the growth rates of doctors' salaries, would be an unjustified extreme. At the same time, the other extreme is also unacceptable – from the recognition of the indestructibility of such practices in the foreseeable future, to conclude that it is pointless and to strengthen the fight against them.
It is necessary to counteract the expansion of informal payment practices for medical care and the spread of payment models at a shadow tariff, since this leads to a decrease in the availability of high-quality medical care for citizens with low incomes. The experience of the past 5 years shows that informal payments can indeed be restrained and even reduced as a result of increasing the salaries of doctors and intensifying the fight against them by law enforcement agencies. Here you can also rely on the entrenched idea of the inadmissibility of extortion and the acceptability of payment in the form of gratitude to patients. It is important to promote the transformation of this position declared by doctors into a corporate norm shared and respected by the medical community. Then the negative impact of shadow payment practices on the availability of medical care and the quality of treatment for those who are unable to pay will be the least.
In the context of such a view of informal payment, it should be stated that the existing methods of law enforcement agencies' struggle with the shadow incomes of doctors are unjustified. Informal payments in the form of a thank-you fee should not be fought. And this, in fact, is what law enforcement agencies are doing when they provoke doctors to receive money from patients, acting by methods applied to ordinary bribe takers. Informal payments are not identical to bribes. It is advisable to focus administrative control measures and actions of law enforcement agencies on combating extortion of money from patients, with the collection of informal payments at established rates.
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