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Social Science & Medicine 62 (2006) 877–887
Informal payments in government health facilities in Albania:
Results of a qualitative study
Taryn Vian
a,
, Kristina Grybosk
b
, Zamira Sinoimeri
c
, Rachel Hall
d
a
School of Public Health, Boston University, Boston, MA, USA
b
PATH, Washington, DC, USA
c
PHRplus Project, Abt Associates Inc., Tirana, Albania
d
Department of Anthropology, Boston University, Boston, MA, USA
Available online 22 August 2005
Abstract
As governments seek to expand access to quality health care services, policy makers in many countries are
confronting the problem of informal payments to medical personnel. The aim of this study was to help health planners
in Albania understand informal payments occurring in government health facilities. Researchers used in-depth
interviews and focus groups with 131 general public and provider informants in three districts. The results suggest that
factors promoting informal payments in Albania include perceived low salaries of health staff; a belief that good health
is worth any price; the desire to get better service; the fear of being denied treatment; and the tradition of giving a gift to
express gratitude. Members of the general public also believe informal payments create uncertainties and anxiety during
the care-seeking process, while providers perceive that informal payments harm their professional reputation, induce
unnecessary medical interventions, and create discontinuity of care. The study showed that focusing on the most
harmful effects and targeting the most vulnerable populations may be one way to gain consensus for policy reform.
Understanding citizens’ and caregivers’ viewpoints is an important step in designing regulatory and bureaucratic
interventions.
r2005 Elsevier Ltd. All rights reserved.
Keywords: Albania; Health care reform; Financing/personal; Health transition; Health expenditures; Qualitative research
Introduction
Informal payments have become increasingly preva-
lent in transition economy countries. Defined as cash or
other things given to government staff for services where
payment is not required by the government, informal
payments are one of many individual coping strategies
adopted by medical staff and patients in countries where
health systems are under-funded, overstaffed, and
burdened with broad mandates for free access to care
(Lewis, 2000;Vian, 2005).
International research on informal payments has
started to become more accessible in the last few years
(Balabanova & McKee, 2002;Ensor, 2004;Falkingham,
2004;Thompson & Witter, 2000). Researchers have
documented positive attitudes toward informal pay-
ments in some countries. For example, studies have
found that informal payments are perceived to
create continuous relationships between patients and
providers, improve staff morale, keep health workers
from leaving the public system altogether, and allow
patients to show respect to providers who please them
ARTICLE IN PRESS
www.elsevier.com/locate/socscimed
0277-9536/$ - see front matter r2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2005.07.005
Corresponding author. Tel.:+1 617 638 5234;
fax: +1 617 638 4476.
E-mail address: tvian@bu.edu (T. Vian).
(Balabanova & McKee, 2002;Chawla, Berman, &
Kawiorska, 1998).
At the same time, informal payments can cause people
to forgo or delay care, sell assets to seek care, or lose
faith in the health system (Akashi, Yamada, Huot,
Kanal, & Sugimoto, 2004;Falkingham, 2004;Lewis,
2000;Thompson & Witter, 2000;Vian, 2003, 2005).
Some studies have shown that the quality of clinical care
is affected by informal payments, with family members
giving injections to avoid paying nurses, and doctors
recommending procedures in order to increase their
income rather than for therapeutic benefit (DiTella &
Savedoff, 2001;Falkingham, 2004). Informal payments
in government-run facilities also create distortions in
health financing systems, draining revenue needed to
support public sector goals and activities (Ensor, 2004).
Informal payments to medical personnel in Albanian
government health facilities are common, despite the
country’s stated policy of providing most health care
services free of charge. Studies conducted between 2000
and 2002 suggest that 60–87% of Albanian citizens
made informal payments to hospital doctors in order to
receive services (Albania Ministry of Health, 2000;
Bonilla-Chacin, 2003). The Albanian Living Standards
Measurement Survey (LSMS) of 2002 estimated that
out-of-pocket expenditures account for more than 70%
of total health expenditures, a higher percentage than
most other Balkan countries (Bonilla-Chacin, 2003).
Another household survey by the PHRplus project
found that out-of-pocket payments for hospitalization
consumed 88% of average monthly per capita house-
hold expenditures; for outpatient acute care, the
equivalent figure was 16.9% (Hotchkiss, Hutchinson,
Altin, & Berruti, 2004). The LSMS and PRHplus studies
indicate that the poor spend a larger percent of their
total per capita consumption on health care treatment
than wealthier individuals. Thus, the practice of
informal payments is likely to hurt the poor more than
other segments of the population.
Albania is beginning reforms to increase resources for
health services, expand access, and increase quality of
care. This qualitative study was designed to help
increase policy makers’ understanding of informal
payments so that they can begin to address the problem
through policy and programmatic changes.
Objective
The study was designed to identify motivations
behind informal payments in Albania, how informal
payments are given, and perceived consequences of the
practice. We sought to develop a better understanding of
concepts and behaviors, not to test hypotheses or
establish facts with statistical significance.
Methods
Albania has a population of 3.1 million, about 58% of
whom live in rural areas. The country is divided into 36
districts, each of which is sub-divided into rural
communes and urban or semi-urban municipalities.
Each district has at least one municipality, and an
average of 8–9 communes. Generally, hospitals and
polyclinics are located in municipalities, health centers
may be located in either municipal and rural locations,
and health posts are situated in rural areas (Cook,
McEuen, & Valdelin, 2005).
The study was carried out in November–December
2003, and included three districts: Fier, Berat, and
Kuc-ova. Fier and Berat each included 2–3 municipalities
and 10–14 communes. Kuc-ova, the smallest and least
urbanized district, had one municipality and 2 commu-
nes. See Table 1 for more information on the study
districts and sample population.
We used focus group discussions (FGDs) and in-
depth, semi-structured interviews to document beliefs
and perceptions that underlie the practice of informal
payments in the Albanian public health sector. The
study gathered views about informal payments from the
general public, clinical care providers, and health
program administrators.
Talking with members of the general public, we used
FGDs to generate data on the range of perspectives and
experiences, while individual interviews helped us to
investigate personal experiences of individuals in more
depth. Eighty members of the general public, including
41 women and 39 men, participated in either FGD or
interviews. We organized four focus groups in each
district, involving a total of 71 people. We also
conducted 9 in-depth interviews. To increase the like-
lihood that participants would be representative of the
population in the three districts included in our study,
we randomly selected two communes and two munici-
palities from each district. During the pilot test we
discovered that it was easier and more natural for people
to discuss these issues in same-sex groups, so we held
separate focus groups for men and women. Some FGD
participants were recruited by going door-to-door,
knocking on every third door and asking one adult per
household to participate. Other FGDs included people
met by chance in the street or in places like parks, coffee
shops, libraries, and hair salons. FGDs were not
anonymous and in some cases participants did know
each other beforehand; the public was eager to discuss
the topic and openly shared personal experiences.
Anonymity among focus group participants is not
advisable in some cultures, as participants may be
reluctant to exchange views with strangers (Ulin,
Robinson, Tolley, & McNeill, 2002). General public
respondents included a range of ages from young adults
to elderly.
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T. Vian et al. / Social Science & Medicine 62 (2006) 877 –887878
Overall 51 providers participated in the study,
including 23 doctors, 22 nurses, and 6 administrators.
Forty providers were interviewed individually, and 11
participated in FGDs. Among the doctors, most were
general practitioners (17), while 6 were specialists in
cardiology, OB–GYN, emergency medicine, and other
areas. All administrators and 65% of doctors were male,
while 95% of nurses were female.
To identify provider respondents, we randomly
selected six urban and six rural facilities in each district.
Facilities selected included all three district hospitals, as
well as health centers and health posts. From the
selected facilities, we obtained a list of all doctors and all
nurses, then randomly selected one nurse and one doctor
from each facility. We chose to invite only one doctor
and one nurse per institution as a precaution to assure
confidentiality and to encourage open and honest
communication in focus group discussions. The topic
was more sensitive for providers than for the general
public, as their professional reputations could be
involved.
During the pilot test, we found that some providers
were reluctant to answer questions when interviewed
alone, but that when interviewed in a focus group they
were more communicative. We thought that perhaps
people felt more protected in the group, and therefore
more inclined to share their opinions. Nurse focus
groups were held separately from doctor focus groups,
again to facilitate more open discussion. However, we
chose not to schedule focus groups in Kuc-ova because
most providers already know each other and we felt this
might make some people reluctant to share their
opinions. Berat providers were also reluctant to
participate in focus groups. In the end, we only held
three provider focus groups (one for doctors, two for
nurses) in Fier. The research team chose two public
health program administrators to interview in each
district based on their availability and interest in
participating in the study.
Researchers obtained written informed consent prior
to participation. See the full study report for detailed
methodology (Vian, Gryboski, Sinoimeri, & Hall, 2004).
Questions asked during the FGDs and individual
interviews covered five main areas: Other than official
fees, what do people give to providers, and how do they
categorize these ‘‘unofficial payments’’? Why do people
make such payments? What are the advantages and
disadvantages of making informal payments? What are
the ways that people make these payments (details about
the process, how people know what to pay, etc.)? What
is being done now about informal payments, and what
should be done in the future? In the in-depth interviews,
the latter question was probed by asking what the
respondent thought about specific reforms under con-
sideration, such as increasing insurance coverage,
official user charges, and community health boards.
The research team analyzed the data using domain
analysis. This type of analysis seeks to create a
systematic understanding of a cultural practice by
describing and analyzing people’s perceptions, attitudes,
and experiences (Spradley, 1979). The team created a
coding scheme using broad categories or concepts to
organize the data, refining the codes throughout the
analysis.
Results
Three areas of findings are discussed, including why
informal payments occur, how payments are made, and
the perceived benefits and disadvantages.
ARTICLE IN PRESS
Table 1
District Pop Urban areas Rural
communes
Hospital/
polyclinics
Health
centers
Health
posts
Doctors Nurses/
nurse-
midwives
(a) General information on study districts
Berat 127,827 2 10 1 18 131 128 290
Kuc-ova 35,338 1 2 1 10 11 32 48
Fier 199,082 3 14 1 24 44 173 336
General public Providers
Male Female Total Doctors Nurses Admin. Total
(b) Sample characteristics
Urban 21 23 44 14 11 6 31
Rural 18 18 36 9 11 0 20
Total 39 41 80 23 22 6 51
T. Vian et al. / Social Science & Medicine 62 (2006) 877 –887 879
Why informal payments occur
Table 2 provides an overview of reasons given by
providers and general public respondents for why
providers take informal payments, and why patients
give them.
Providers
On the provider side, medical personnel feel that their
work is undervalued by the government. Providers think
patients make payments to supplement providers’
income, knowing that medical personnel are underpaid.
People say: ‘Doctor, take this 200 lek, I prefer to pay
you, better you than the government, because the
government doesn’t give you anything, just a
monthly salary of 20,000 lek.’ This is the new concept
introduced by the people to reward the work of the
doctor. (doctor)
Members of the general public often made similar
statements, saying that providers accepted informal
payments because they were not well paid by the
government: ‘‘I say that the payment I give is considered
as a remuneration for her work.’’ (public)
Other factors mentioned by providers and adminis-
trators included the providers’ need for a higher
standard of living (‘‘The doctors should meet their
needs. It costs 50 or 60 million lek to buy a house these
days.’’) and the fact that health care is a commodity so it
is natural that people should have to pay for it (‘‘In the
capitalist system, money stands in the center of every
thing, it is the main point, the key of living, and people
who we can consider smart ones, they pay or give money
to the doctor directly, not the government, to protect
their health.’’).
Socialization during medical training was mentioned
as a possible driver for informal payments.
The great professors of Tirana are near the ministry
and it is these professors who determine these
payments. The doctors from Berat and other cities
just observe and learn from these professors. The
Berat doctors learn how much money these profes-
sors ask for, and when they come here they behave
like them. These doctors sometimes serve as ‘man-
agers’ of their professors during the period of
specialization. (administrator)
Lack of social connection may also increase providers’
willingness to ask for or accept informal payments. For
example, some informants felt that in small towns or
neighborhoods, providers are reluctant to directly
demand payments from patients with whom they are
acquainted. ‘‘For example, I don’t pay the doctor who
works in the health center in my neighborhood, while
when I go in the polyclinic I pay.’’ (public) Ties between
providers and residents in rural areas and smaller urban
communities may deter informal payments because
providers would be embarrassed or feel loss of profes-
sional reputation if people were to know they were
accepting informal payment.
Kuc-ova is a really small town, and almost all the
people know each other. The city has 10 or 15
specialists and all know us; therefore, we can’t do
similar things, because we know each other. (doctor)
ARTICLE IN PRESS
Table 2
Reasons for informal payments
Reasons why providers ask for or accept Reasons why patients offer or give
Financial problems, low salaries
To have a higher standard of living
Market-orientation (health care is a market, people should
pay)
Socialization during medical training (learning how to solicit
payments)*
Lack of social connection or personal relationship
Not to insult patients, because patients want to give gifts or
make payments
Recognition that providers are not paid adequately
For a feeling of security (did all that it was in your power to
achieve good outcome)
To motivate the provider to provide more attention, better
service
For fear that sub-standard care will be provided if you don’t
pay
Because you must pay or you will not be seen or receive any
care
To ‘‘warm up’’ or create a closer provider–patient
relationship*
To expedite or speed up care
Because of gratitude, appreciation; to reward the provider
(may be called a gift)
Note: Reasons marked with (*) were mentioned only by providers. All other reasons were mentioned by both providers and general
public.
T. Vian et al. / Social Science & Medicine 62 (2006) 877 –887880
According to some providers, villagers who come to
the city for treatment are asked to pay more than city
dwellers because the villagers want more rapid service
(the assumption being that they want to quickly get back
home). In addition, the villagers do not have personal
relationships with the providers in the city so may be put
under more pressure to pay.
yThere is a kind of abuse by the doctors. In the
moment they understand the patient is from the
village, the doctors set forth other financial demands
to them. The ones living in the city pay less. (nurse)
Finally, providers suggested that they accepted
informal payments because the patient wanted to ‘‘warm
up’’ the provider–patient relationship, and to not insult
the patients. Providers said they accepted the informal
payments because they were intended as gifts, or were
voluntary contributions to the patient’s care. ‘‘If the
patient is satisfied with my work at the end of the
examination and gives me something, why should I not
take it? Bakshish (tips) are accepted by everyone.’’
(doctor) Informants also noted that informal payments
may be on the rise in general because health personnel
face no consequences for withholding services to get
informal payments.
Patients
Informants noted many reasons why patients give
informal payments. As noted earlier, patients do
recognize that providers are not well paid, and at times
consider their informal payment as a contribution to
their care. At the same time, some public informants
thought that doctors have gotten too greedy, and many
members of the public were upset that they should have
to pay informal payments at all since they pay into the
state medical insurance.
[Nurses] said that their salaries were low, and that
they needed to feed their children. According to me, I
know that we are in a transition period and that the
situation will not get better by giving informal
money. We must all pay insurance, so that the
doctors receive better salaries and do not need to ask
for informal payment. (public)
Both provider and public informants cited a cultural
belief that there is no substitute for good health. Thus,
payments are sometimes willingly given to ensure
restoration of good health, a ‘‘priceless’’ commodity.
Informants also perceive that patients willingly give
payments so that they will get better attention or faster
care. ‘‘If you pay for the visit after the service is
provided, you will wait for a long time and will not
receive good treatment.’’ (public) In fact, some providers
said that when they themselves need care they make
informal payments to ensure the best possible treatment.
At the same time, many providers and public
informants described cases where no treatment would
be given at all if a payment was not made. In such cases,
informal payments are made because there is no choice.
If you go to the hospital the doctor doesn’t touch you
if you don’t pay 5000 lek. And this doesn’t happen
only in Berat but also in Tirana, if you don’t pay no
one touches you. (doctor)
Some public informants noted that individuals from
rural areas who seek care outside their communities may
pay more frequently or in greater amounts. ‘‘In hospitals
those who tend more to make informal payments are the
village peopleythey have this fixed idea that they must
give something to the doctor.’’ (public)
Finally, public informants acknowledged that some
‘‘unofficial payments’’ are meant as gifts to express
gratitude. ‘‘When a baby boy is born, we give the
midwife 1000 lek, because in Albania we love to give
birth to boys.’’ (public)
Some public informants felt that informal payments
did not commonly occur prior to the 1990s. Many
compared the current level of informal payments to the
more restricted level of payments during the time of the
dictatorship.
Fifteen years ago I hospitalized my daughter in the
Military Hospital in Tirana because she had burns all
over her body. The doctor accepted nothing from me;
nothing at all! Doctors of that time were very sensible
and human; shame on today’s doctors; the doctors of
today leave you die if you do not give money to them
y(public)
How payments are made
With this question, we sought to understand how
patients decide what to pay, how amounts of informal
payments vary, what types of services involve informal
payments, and the process for payment.
How people determine what to pay
When communicating about informal payments,
several provider informants said the patients ask what
they owe the doctor or nurse. Public informants also
reported that medical personnel directly ask for pay-
ments. Informants said that the process takes place in
the open and is not seen as something that must be
hidden. Public and provider informants also thought
that patients estimate how much to pay by asking
friends and relatives based on their past experiences.
Table 3 summarizes some of the ways that providers
convey to patients the need to make an informal
payment, both directly and indirectly.
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T. Vian et al. / Social Science & Medicine 62 (2006) 877 –887 881
Variation in amounts of payments
Informants described many factors that they felt were
associated with the amount of informal payment, i.e.
what would make a payment higher or lower. These are
summarized in Table 4.
Rural providers in Kuc-ova and Fier believe that the
poorest and elderly do not make informal payments,
and that the amount anyone pays is very nominal for
visits to the doctor. More than in Berat, providers in
Kuc-ova and Fier emphasized that they avoid accepting
informal payments from vulnerable groups. The level of
informal payment also seems to be somewhat dependant
on how well the individual is acquainted with doctors
and hospital staff.
A friend of mine had asked the doctor how much did
an eye operation cost. The doctor had told her that it
cost over 10,000 lek but the doctor would make a
discount for her because he knew she didn’t have
money. (public)
Although some public and provider informants
described practices of exemptions to protect the vulner-
able, many informants had stories of very poor patients
who were still expected to make informal payments.
Some stated that the poor and pensioners must borrow
money to pay for treatments, diagnostics, and surgeries,
which can be economically catastrophic. For example, a
nurse described a situation she witnessed while not on
shift at the hospital, but waiting for a relative:
[A] person whose trousers were full of patches came
in. He was holding a baby in the arms. At the first
moment the baby looked as if it was dead. There was
something on his faceyWhile we were waiting the
emergency doctor came. He said: ‘Now you should
give me 50,000 lek. I will be back in a while. During
this time you can find the money.’ I do not know
what happened lateryI felt very sorry because the
baby looked as if it was dead. Another doctor was
there at that moment. He was very mad with the way
the emergency doctor behaved so he decided to
operate on the baby himself. (nurse)
Type of service and provider
Many informants said that informal payments are
highest for complex or difficult services such as surgery,
obstetrics, and cardiovascular or liver disease. Accord-
ing to one public informant, ‘‘It is known that the
payments vary. The easiest operations have lower
informal payment assignedy.’’
Provider and general public informants said that
general practitioners take informal payments, but in
amounts less than specialized doctors. Doctors or
surgeons with a higher reputation or more skills and
training are thought to provide higher-quality service
ARTICLE IN PRESS
Table 3
How providers convey that patients need to pay, according to public informants
Staff talk about their difficult
financial conditions
The nurse said: ‘‘1000 or 2000 lek are not a big deal. Our salary is not enoughy’’
‘‘When the doctor finishes the examination, he says ‘Do you know that we live under market
economy conditions?’ So you have no other choice but just to give him the money, because if you
don’t give him the money he would say, ‘Are you here to be examined or to talk?’’’
Leave money on the table,
showing that others have paid
‘‘The doctor leaves some money in his working desk, so that when the patient goes there to be
checked, he is obliged to give moneyyWith this gesture he tells you that you have to pay.’’
Ask directly ‘‘Ryshfet (bribes) are flatly asked for by the doctor.’’
‘‘They ask to be paid before the service provided. In the case of my aunt, they had asked her
before the operation.’’
Act in an indifferent or
unfriendly manner
‘‘The doctors speak in an angry voice to you.’’
‘‘We understand from their reaction, when they are not satisfied you need to increase the
amount.’’
Ask ‘‘who is with the patient’’? ‘‘When the doctor saw us, he asked, ‘Who accompanies the patient’? When he asked who
accompanied the patient, he intended to ask who would be the persons to give the money.’’
Withhold or delay care, pretend
to be busy
‘‘The doctor wants 2000 lek for the prescription, otherwise he will not give it to youy’’
‘‘[The nurses] don’t ask directly, but if you don’t put the money in their pockets, they don’t
comeyor they come too late.’’
Staff tell you patient must buy
own medicines
‘‘They tell you to buy a large amount of medicines at the drug store because the doctor owns that
drug store.’’
T. Vian et al. / Social Science & Medicine 62 (2006) 877 –887882
and expect higher informal payments. Some doctors
perceived that nurses receive more informal payments
than doctors since nurses have more contact with
patients, while other informants perceived that doctors
were paid more than nurses.
It depends on the way the doctor presents himself or
from the reputation as a good specialist. So if you
want to go to doctor X for a visit the quality of this
visit will be high and the price you need to pay will
also be high. It depends on the type of operation, if
the operation will be a difficult one or less
difficultya hysterectomy is more difficult than a
normal delivery. (doctor)
Informal payments made by patients and their
families extend well beyond doctors to other health
workers and hospital employees. Nurses may need to be
paid to make sure the patient gets a room, or to have IV
drips set up, or injections and medications administered.
Some public and provider informants reported that it is
an Albanian tradition to give something to the person
who brings you good news; therefore, nurses rush to
announce the birth of a child. Public informants
reported paying even the cleaning personnel and the
guards.
People will be obliged to pay. They need to start by
paying the guard at the door. After they have paid
the first guard they will need to pay the other guard
at the other door. And so on until you will reach the
doctor. (public)
Brokers or ‘‘Managers’’
Several Berat informants mentioned that in hospitals
in Berat or Tirana, a person described as a ‘‘manager’’
may collect payments and act as an intermediary
between the doctor and the patient. ‘‘There are brokers
who take care of these things. They are like manage-
rsyIf there is a broker these payments are made
before.’’ (doctor) The use of brokers was described in
connection with busy doctors, especially surgeons.
Brokers may or may not be medical personnel.
There are cases in which the nurse decides how much
patients need to pay. In other cases it is the guard
who decides how much money the doctor will take
and after that the guard gets paid from the doctor, he
gets his part after the visit. If a specialized doctor
recommends another doctor to make an X-ray, the
X-ray doctor tells the patient how much money is
needed to pay the doctor who did the recommenda-
tion. Those doctors who have a lot of work usually
make use of a ‘manager’ who serves as a broker.
(administrator)
Informants did not mention managers working in
settings other than hospitals.
ARTICLE IN PRESS
Table 4
Explanations given by providers and public informants for variation in amounts of informal payments requested or given
Patient-attributes
Economic status of patient (poorer people may pay less)
Relationship with provider (if patient and provider have relationship, patient may pay less)
Ethnicity (immigrants may pay more, less likely to complain)
Whether the patient resides in locality of clinic (may pay less where one lives)
Political position of patient (patients who have political connections or know rights are less pressured to pay)
Provider-attributes
Qualification of provider (more training, experience, good reputation or a higher level appointment command higher payments)
Specialist versus generalist (specialists command higher payments)
Scarcity (if there is only one provider, the payment may be higher)
Service-attributes
Facility location (generally pay more at urban locations)
Facility type (more at hospitals)
Inpatient versus outpatient (more for hospitalizations)
Specialty (more for surgery and obstetrics)
Procedure complexity (more for complex procedures)
Level of technology (more for higher technology)
Other contextual factors
Economy: transition from planned to market economy has increased informal payments over time. Government revenues can’t
support salaries of workers. Also a general trend toward valuing monetary transactions more than before.
District: payments seemed more pervasive and higher in Berat than in either Fier or Kuc-ova. May be due to service attributes such as
higher level of urbanization, or other contextual differences such as level of social distance, familiarity of patients-providers.
Social norms: over time, the status or prestige associated with saying you made an informal payment may be increasing, driving IPs
up.
T. Vian et al. / Social Science & Medicine 62 (2006) 877 –887 883
Perceived benefits and disadvantages
For the most part, Albanian informants could
describe few advantages or benefits to informal pay-
ments. Even providers, who were quick to rationalize the
process as something patients want, and who one might
think have the most to gain, could think of few benefits.
The main perceived advantages of informal payments
included gaining access to services and improved quality
of care.
Informal payments are seen as a needed motivation to
get medical personnel to perform their duties. For
example, patients making informal payments would
receive IV solutions and medications that they believed
otherwise might be withheld.
A woman had an appendicitis operation and she was
suffering a lot from the pain. She told the nurse she
needed tranquilizing but the nurse did not help her. It
was only after she put 200 lek in the nurse’s pocket
that she gave her the sedative. (nurse)
Public informants also perceived that quality of care
improved when informal payments were made. Patients
who made informal payments thought they would be
operated on with more care and attention. Provider
informants typically stated that although patients may
view informal payments as a way to get better service,
the same quality of care was given whether the payments
were made or not.
Some provider informants reported that they felt the
relationship between providers and patients was im-
proved through informal payments. They described
developing a closer, more personal relationship with
patients who give informal payments. ‘‘They get to
know each other while they pay and get paid. This
warms up the relationship.’’ (nurse) Yet, often the public
informants disagreed, saying that informal payments
had no positive effects on their relationship with the
provider beyond ensuring that any care was received at
all. ‘‘All the other patients said that if you did not pay
the nurse she would make the injection with water, or
would not appear at all.’’ (public)
Disadvantages of informal payments included erosion
of professional image and trust, inducement of unne-
cessary medical interventions, discontinuity of care or
poorer quality care. Often providers felt demeaned by
accepting the informal payments. They said they would
be embarrassed to be gossiped about by neighbors and
friends if they were soliciting informal payments, and
said that their reputation and standing in the community
were more valuable to them than these payments.
These payments make me feel like I was the ‘servant’
of this patient. It feels like the patient is feeding me. I
provide health service and I don’t like to take money
from someone who doesn’t have shoes to put on.
(doctor)
Some public informants also mentioned feeling shame
or humiliation from the informal payments. They talked
of how the medical personnel only ‘‘look you in the
hands’’ (to see what you are able to pay) instead of
treating the patient with respect.
Administrator informants described concern about
how informal payments can adversely influence a
doctor’s choice of treatment for the patient. In addition,
provider informants felt clinical care problems were
created by the practice of relatives handling the informal
payment on behalf of the patient. The leverage gained by
patients through making payments to the provider
might actually compromise the patient’s quality of care:
Let me take the case of an operation as an
exampleyIn the case the doctor is paid [informal-
ly]ythere will be not 2 or 3 persons but 10 persons
in the patient’s room. There will be continuous going
in and out, the patient will even ask for things not
allowed for his health, because of the affinity created
between the patient and the doctor, and the latter will
feel obliged to offer some privileges to the patient-
y[such as] requests for different kinds of drugsy
(administrator)
‘‘No payment, no treatment’’ was an experienced
reality for members of the public in all the research
locations. The main disadvantage to informal payments,
for many people, is that if someone cannot afford to pay
or cannot borrow the money to make the payment, they
may not get care they need. Public informants wanted
the practice stopped because it is unfair and abusive,
hurts the poor and vulnerable who cannot afford to pay,
creates uncertainties and anxiety during the care-seeking
process, and corrodes the patient–provider relationship
as doctors look ‘‘only at your hands.’’ Providers would
like to see the practice decrease because it harms their
professional reputation, subjects them to social sanc-
tions (ostracism or gossip), and is demeaning. Most
providers indicated that they would prefer not to be in
the situation of accepting informal payments. ‘‘We are
losing everything, no one respects us, we are losing our
humanity, all the values we used to have.’’ (nurse)
At the same time, health is seen as a priceless thing in
Albanian culture, and people are willing to pay to gain
access to care and for the prospect of better service.
Some people stated that they would find the money
however they could, even if it meant going into debt, to
make the necessary informal payments. People also
expressed feelings of responsibility for the health of
family members and relatives, and this may continue to
drive Albanians to make informal payments to avoid
feeling guilt if their relative does not recover. ‘‘The most
important thing is that you should pay the doctor,
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T. Vian et al. / Social Science & Medicine 62 (2006) 877 –887884
because he will never forget the face of someone who has
not paid him, for the rest of his life.’’ (public)
Both provider and public informants commonly
discussed their concern about the vulnerability of the
poorest citizens, such as pensioners, to the demands of
informal payments.
Discussion
Analysis of the practice of informal payments is
complicated by some confusion of terms. First, for the
general public in Albania, there seemed to be some
problems distinguishing official from unofficial pay-
ments. At times people reported being told they had to
pay an ‘‘official’’ charge, but that they could choose
whether to pay the provider directly or make a special
trip to the office. Often people preferred to pay the
provider directly, either for convenience or because they
felt a direct payment would motivate the provider to
give better care. Finally, some informants reported
seeing ‘‘unofficial price lists’’ which might actually be
official price lists for non-insured patient user charges or
insured patient co-payments. The researchers observed
that policies regarding co-payments or exemptions for
insured patients were not really understood and may not
be uniformly applied.
These observations suggest that some ‘‘informal
payments’’ may actually be authorized charges which
are not being collected in transparent ways, or are being
siphoned off at the point of collection. This problem
needs to be studied further to identify appropriate
interventions.
In addition to confusion over official versus unofficial
fees, this study had difficulty distinguishing gifts from
other types of informal payments, namely bribes. The
Albanian informants often differentiated between gifts
(dhurate,peshqesh) and bribes (ryshfet) based on
characteristics noted in the literature: gifts are voluntary,
given after the service is delivered, of token size, in-kind
(Balabanova & McKee, 2002;Werner, 2000). But
informants would go on to give many examples of
bribes that had all the characteristics listed above, or
gifts that had none. The most salient characteristics of a
gift turn out to be the least observable: that someone
intends it to be a gift, and that it is an expression of
gratitude or appreciation. Unfortunately, as they inter-
act, providers and patients are often uncertain about
what the other expects and intends.
In detailing the process of informal payments in
Albania, several findings were surprising. First, the role
of unofficial ‘‘managers’’ in brokering informal payment
deals between medical providers and patients was not
previously known to health planners in Albania. While
we only heard of people encountering ‘‘brokers’’ in
hospitals in Berat and Tirana, it illustrates an unex-
pected level of institutionalization of informal payments.
In establishing bureaucratic controls and changing
procedures to strengthen health institutions, planners
will need to be aware of the role of brokers in the current
informal payment process.
Secondly, we found some evidence of informal
payment discounting based on ability to pay in
Kuc-ova, but not in other areas. This finding is
important because it shows that the informal system is
not automatically providing safeguards for the very
poor and vulnerable populations.
Finally, the study findings show that the interaction
between patients, relatives, and various personnel at the
many service delivery points is complex. As patients
navigate the system, they seek information from other
patients, friends, and relatives to try to establish who
and what they need to pay to get proper attention, or
any attention from personnel. Patients must read
indirect clues from providers, in addition to, in some
cases, dealing with brokers outside the health system or
nurses to determine amounts to pay. Patients experience
much ambiguity and uncertainty. When directly told
they need to pay, they also do not feel certain about
which are official fees and which are informal payments.
Many doctors feel uncomfortable interacting with
patients because they do not want to appear to be
soliciting informal payments.
Implications for health policy reform
The consequences of informal payments, and the
implications for reform, depend to a large extent on the
motivation for the payment. For example, payments
made to express gratitude may have consequences that
are different and less grave than those of payments made
because the patient did not understand what she was
entitled to within the public system, or payments given
to ensure adequate care (whether demanded by the
provider or not). In addition, despite general agreement
that informal payments are a serious concern that needs
to be addressed, there are individual motivations to
continue informal payments. For example, physicians
and nurses may currently earn informally a much higher
salary than they would be able to earn even in a well-
financed public system, and patients are able to get some
assurance and peace of mind that they are able to
access and receive better service. As researchers in
Poland suggest, ‘‘In a system where both physicians and
patients have come to understand the advantages
of informal payments, any change therein may
require many attitudinal adjustments’’ (Chawla et al.,
1998). This presents challenges for reform. Specific
implications of study results for policy reform and
health system strengthening in Albania are described
further below.
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Focusing on the most harmful effects and targeting the
most vulnerable populations may be one way to gain
consensus for policy reform
High level policy support for reforms usually requires
involvement of a strong coalition of stakeholder groups
who see common interests to be achieved through
change. Yet, this study found differences in how
providers and the general public view informal pay-
ments. For example, general public informants were
more likely to see informal payments as forced, while
providers said they thought patients were making gifts
or voluntary contributions to the cost of their care.
These differences in perceptions need to be considered
when developing policy and programmatic interven-
tions.
The policy reform agenda on informal payments
should focus on the most harmful effects of informal
payments and include strategies to protect the poor and
elderly who live on a meager income. This approach will
make it easier to reach consensus, as most informants in
the study agreed on the need to provide protection to
very vulnerable groups.
Insufficient provider remuneration is the factor most
commonly cited as motivating informal payments, and
needs to be addressed
From a political perspective, a policy reform agenda is
more likely to be supported by physicians and nurses if it
includes actions to increase remuneration. With or
without salary increases, citizens’ and providers’ actions
regarding informal payments may be influenced through
a greater understanding and public discussion of how
providers are paid, salary differences among types of
personnel, and other details about the fairness and
adequacy of public sector provider compensation
policies.
In the short term, systems-strengthening activities
could focus on increasing the financial and performance
accountability of the official fee systems already in place
in Albanian hospitals. Current Albanian regulations
allow hospitals to retain revenue and use it for salary
supplementation, as one hospital has done to increase
physician salaries four-fold (Vian, 2003). This strategy
has been used successfully in Cambodia to reduce
informal payments (Barber, Bonnet, & Bekedam,
2004), and may also be possible in other countries if
statutes exist or can be put in place to allow fee retention
at the facility level. Larger scale reforms to payment
systems and human resources policies for government
workers may also be needed.
It may take some effort to persuade clinicians that it is
in their interest to advocate for policy change rather
than simply accepting informal payments as a way to
increase salaries. Yet, this study demonstrates that many
physicians and nurses feel conflicted about informal
payments and wish they did not have to accept them.
These perceptions and attitudes can be built upon to
create effective advocacy for public policy change.
The practice of informal payments may be reducing public
willingness to participate in the social insurance system
The study findings showed that both insured and
uninsured patients were making informal payments. At
the same time, some providers claimed not to charge
official fees to uninsured patients for fear the official fees
would be mistaken for informal payments. Many people
did not know where to find official price lists or to whom
those prices apply. These findings imply that the
unwillingness of some people to enroll in the national
health insurance program may be related to the practice
of informal payments. Education programs could
improve the public’s understanding of how social
insurance and official user fees work.
More research is needed to understand the variation
in informal payments among services, and how this may
affect care-seeking decisions. A future study could
stratify informants according to prior care-seeking
behavior and type of facility or provider. This would
allow better understanding of how beliefs are influenced
by the experience of seeking care and having made (or
not made) an informal payment in different settings.
Health reforms cannot easily separate or ignore gift-
giving
Although gifts may be more acceptable than these
other types of informal payments, there are still
concerns. First, the research shows that there are not
clear boundaries between bribes and gifts. ‘‘Have a
coffee’’ may be a gift, but it was also a phrase used to
describe an unofficial payment given (willingly or not) to
ensure adequate care. In addition, gifts may be used to
entice or motivate providers’ future care-giving beha-
vior, and the anticipation of receiving gifts could
influence provider decisions. Gift giving may be an
excuse for providers to accept all kinds of informal
payments.
To help identify informal payments that are of more
concern (i.e. bribes), planners may want to examine the
possible benefits of promoting ways for people to thank
government workers through the institution, rather than
individually. Part of the tradition of gift giving
throughout the Balkan region comes from a social
obligation to show appreciation for a service. In some
countries, people can express thanks to public employees
or health workers through gifts to the institution (Rose-
Ackerman, 1999). Collective gifting fulfills the social or
moral obligation while reducing the problematic materi-
al incentive the gift might represent.
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Increased transparency and citizen oversight may be a
useful complement to regulatory and bureaucratic reforms
Most public informants in this study thought that the
state should take responsibility for ending informal
payments. This reliance on government to provide
solutions is not surprising given Albania’s recent
transition to democracy. But a key concern about the
practice of informal payments is the lack of transpar-
ency. Actions to increase transparency often are effective
when they involve public oversight and involvement.
When asked about the role of communities in addressing
informal payments, some providers and public infor-
mants described potential benefits in having additional
transparency and involving citizens. This is another
option that could be explored.
Conclusion
In the eyes of providers and the public, informal
payments are both a necessary coping mechanism and a
destructive practice that hurts efficiency, trust, and
health. Providers and members of the general public do
not always have the same perceptions or beliefs about
motivations and expectations for informal payments
when interacting during service delivery. Public discus-
sion is needed to air these differences and to explore
common interests. Accountability will be enhanced as
government officials and civil society work together to
identify possible solutions and decide what roles govern-
ment and the people should play in implementing change.
Acknowledgments
The funding for this research was provided by the US
Agency for International Development (USAID),
through the Partners for Health Reformplus (PHRplus)
Project, under Prime Contract No. HRN-C-00-00-
00019-00 awarded to Abt Associates, Inc. The opinions
expressed herein are the authors’ and do not necessarily
reflect the views of USAID. The authors wish to thank
Sara Bennett and Kate Stillman for participation in
study development and implementation. We also
acknowledge Merita Xhumari, Elona Nasufaga, and
Altin Malaj for their input during the research, and
Lucy Honig, Rich Feeley, and two anonymous reviewers
for very helpful comments on earlier versions of this
manuscript.
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