Reasons for informal payments from the perspective of health care providers and recipients: a qualitative study in Iran

BACKGROUND: Informal payments are one of the major obstacles to health system reform in many developing countries, and its elimination is on the agenda of health system policymakers in many countries, including Iran. This study was conducted to identify the causes of informal payments in the Iranian health system. METHODS: This was a qualitative and exploratory study. The study environment included the Ministry of Health, physicians' offices, medical universities, and hospitals and health centers. The study population included health care providers (physicians and hospital staff, managers, supervisors, and nurses) and health care recipients (patients or patients who had a history of dealing with informal payments). Data were collected using open-ended questions and semi-structured interviews. Snowball sampling method was used to select managers, chief executive officers (CEOs) and nurses. Convenience sampling was used to select physicians due to their lack of participation and cooperation. Content analysis method was used to analyze the data. RESULTS: Reasons for informal payments were divided into 4 themes including: Economic factors (improper tariff valuation of services; failure to increase tariffs proportionate to inflation; lack of comprehensive participation of stakeholders in determining tariffs; tariff inconsistency in the public, private and charity sectors; etc.); socio-cultural factors (decreased social capital of the medical community among the people; improving the quality of life; incorrect comparison of providers' income levels with the income of doctors in other countries; existence of a culture of gratitude and appreciation; health as a priority for society; pride of service recipients; pride of service providers; etc.); service delivery challenges (high professional skills of the doctor; use of modern medical equipment; the monopoly of some doctors, etc.) and legal-political factors (inadequate monitoring by upstream organizations; lack of strict rules; difficulty of proving informal payments; presence of stakeholders in management and policy making processes). CONCLUSIONS: Knowing the causes of informal payments can help reduce or eliminate it. The results of this study identified the causes of informal payments in the Iranian health system. Accurate knowledge of the needs and motivations of both health care providers and recipients can be effective in accurately identifying and eliminating this phenomenon.