Elsevier

Health Policy

Volume 109, Issue 1, January 2013, Pages 23-30
Health Policy

Informal payments for maternity health services in public hospitals in Greece

https://doi.org/10.1016/j.healthpol.2012.10.012Get rights and content

Abstract

Background

Private health expenditure for consuming maternity health services has been identified as an issue within public hospitals.

Aim

To estimate level of private health expenditure, in the form of informal payments, for maternal services in public hospitals in Greece.

Methods

The study population consisted of 160 women who had recently given birth in three provincial general hospitals and one general hospital in Athens. A three-part questionnaire was developed in order to collect financial information regarding the use of public obstetrics services in Greece.

Results

The mean age of respondents was 29.5 (±5.6) years. There was a high rate of informal payments with 74.4% of women involved in informal transactions. Mean total private payments were €1549 (±992), representing 7.9% of the mean annual per capita income in Greece. Mean informal payment was €848 (±714). For 56.3% of the respondents, it was at the obstetrician's request, on top of formal payment of €701 (±1351). Total informal payments were higher for women who gave birth in Athens (p < 0.001), for Greek women compared to non Greek (p < 0.001) and for deliveries that were conducted by women's personal obstetrician (p = 0.001).

Conclusion

There is a large black economy in the field of obstetric services, as 74.4% of women who used public maternity services had to pay under-the-table payments corresponding approximately to the net salary of an intern physician. There is a need for the state to adopt innovative strategies and mechanisms in order to reduce informal payments for obstetric services in the public sector.

Introduction

The Greek health care system is a dual system funded on a 60–40% basis from public and private sources. Public expenditure, at 66% of total health expenditure in 2010, is financed by 35% by general government and 65% by social security funds [1]. Tax revenues are derived from both direct income taxation and indirect taxes on goods and services (general and hypothecated), with the latter representing the largest proportion (58.4% of total tax revenue) [2]. Out of pocket payments represent 40% of total health expenditure [1], making the Greek Health System one of the most “privatised” among European Union (EU) countries [3]. A significant proportion of out of pocket payments are informal payments, as user charges represent only a small proportion. [2].

The high level of informal payments for health care poses a significant financial burden on Greek citizens. According to Balabanova and McKee, informal payments are defined as a monetary or in kind transaction between patients and health professionals for public health services, theoretically free of charge, and are caused by inadequacies of the health system [4]. The most common type of informal payment is where providers exploit their power or market position in order to extract a payment from patients and one of the most common ways to do so is for health professionals to delay treatment until a payment is made [5].

Informal payments are very common in many European countries, especially those of the former Soviet Union and Central & Eastern Europe [6], [7], [8]. In some cases, informal payments constitute an important source for sustaining the health care system as for example in Georgia and Azerbaijan, having at the same time severe consequences on both equity and efficiency [7], [9]. In the Czech republic 59% of in hospital patients reported an informal payment [8] while in Poland, 69% of patients in non regional hospitals and 61% of patients in regional hospitals reported “envelope payments to physicians” [10]. Similar percentages are reported from the Slovak republic (60%), Bulgaria (43%) and Russia (53%) [5], [6], [7]. In some countries informal payments represent a remarkable part of per capita income. For example, according to published studies in India and Bulgaria informal payments constitute 35% of the monthly income. In Armenia, the respective figure has been estimated at 130% and in Albania at about 40% [11]. Informal payments for inpatient care are also considered to be a remarkable part of a household budget in Eastern Europe countries, accounting for 46% of all out of pocket payments in hospitals. [12].

According to a Greek study published in 2008, 36% of inpatients reported at least one informal payment to a physician [13]. Those payments, which represented almost 20% of the total hospital household expenditure, are not a cultural characteristic or a conscious luxury choice, but an established forced social behavior made necessary in the course of seeking easier access to quality treatment [3]. It was also reported that none of the socioeconomic characteristics of the respondents are related either with the probability or the size of extra payments [13], which is a compatible result with previous studies [14].

As a result, households (and especially poor ones) resort to various strategies to make informal payments such as selling property, borrowing from relatives or even banks [15], [16]. Evidence from Romania and Georgia is that poorer patients make significant sacrifices to pay for essential health services, which in some cases they could not afford. In Kyrgystan, one in three patients reported borrowing money for inpatient care, while in the rural areas, 45% of inpatients sold property to cover hospital costs [11].

Concerning the impact of informal payments on efficiency and equity, a “compulsory” payment, may deter the poor from utilizing necessary health services, or place a disproportionate burden on their shoulders. This is not just an equity problem, but it also affects resource allocation, if services are not consumed by those who would benefit most. In the case, of urgent health services, the need for informal payments may cause a person to forgo other essential expenditure. Even voluntary, informal payments from the equity perspective imply unequal access for equal needs (horizontal inequity). Furthermore, supply and demand (or need) determine the impact of informal payment on efficiency, and in this respect it becomes important in the case of supplier-induced demand [8].

An example of the former is public obstetric services in Greece, where under-the-table payments are a common feature and the choice of delivery (cesarean section-CS vs vaginal births-VB), is driven by physicians. In Greece, 114.766 labors took place in 2010 (www.statistics.gr), half of which were conducted in public maternity units. The rate of cesarean sections in Greece is currently by far the highest in the EU. More than 50% of deliveries include CS while the corresponding rate in the EU in 2007 was 24% [17]. Mossialos et al. have shown that 60% of deliveries by Greek women are through CS in both public and private hospitals. Interestingly, this figure falls to 5% for Greek Roma women and 7% for immigrants, two categories with decreased ability to pay [18]. However, the extent of under-the-table payments for obstetric services in Greece is largely unexplored, and further research is needed to understand the issues involved. This article seeks to address this information gap.

Section snippets

Aim and methods

The aim of this study was to investigate informal payments during the prenatal period and delivery in public hospitals and to estimate private health expenditure during a labor at a public hospital. The sociodemographic characteristics of women who gave birth in public hospitals and the association between informal payments and the delivery method (CS, VB) were also analyzed. A three-part questionnaire was developed to collect information for unspecified and unknown economic aspects, regarding

Results

Two hundred fifty eight women who had recently given birth were asked to participate in the study, and 160 accepted, with a response rate of 62%. The mean age of participants was 29.5 (±5.6) years. Demographic characteristics of the participants are shown in Table 1.

Fifty-seven percent (n = 91) of the deliveries were Cesarian Sections (CS). The main reasons for selecting cesarian section were previous cesarian section (21.2%) and abnormalities of the fetus (21.2%). Of the women who underwent CS,

Discussion

The frequency and height of informal payments in maternity units in Greece shows that it has become a common and accepted practice, posing, however, a significant economic burden on household budgets. Although there is no published research in Greece regarding informal payments for childbirth, limiting the chance to validate the results, data from similar studies indicate that 36% of patients admitted in public hospitals reported at least one informal payment to a doctor. The odds of making an

Conclusion

The findings suggest that in Greece, there is a large black economy in the field of obstetric services, since 74.4% of women who used public maternity services had to pay under-the-table payments which for the year 2009 were estimated at 848€ corresponding approximately to the net salary of an under-training physician. The majority of Greek families which use public hospitals for giving birth to their children are confronted with significant informal payments, reaching 42.4% of the mean monthly

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