Introduction

Corruption affects health systems around the world [1–5]. According to García [6], the health sector is an attractive sector for corruption due to its complexity and the asymmetry of power between users and providers. Corruption in service delivery can be classified in six common types: absenteeism, informal payments, embezzlement, corruption during service provision (actions or medical treatments that were not necessary and that generate an economic or particular benefit to a third party), favoritism, and manipulation of data. Many forms of corruption, such as the diversion of funds, bribes as economic barriers to care, health personnel who do not attend at the established hours and do not provide the care that the population should receive, make it much more difficult to implement universal health coverage (UHC) [7]. Corruption in health systems limits access to health services and weakens all the dimensions of UHC: limiting access, undermining quality, increasing costs, and worsening inequity, each of which impedes health systems from delivering on the promise of better health for all [8]. Corruption in the health sector is not only a legal or economic phenomenon, but a social phenomenon: a set of practices that are embedded and normalized in the routine experience of health service users [9, 10]. Poor oversight systems and weak accountability mechanisms are associated with greater corruption in health systems [9].

In Peru, as in many Latin American countries, oversight systems and accountability are complicated by the fragmented and inequitable nature of the health system [11]. In 1975, Peru initiated a modern organization of its health system, becoming the first country in South America to do so [12]. However, the lack of a state policy led to inefficient performance, discontinuity, and a lack of assessment. For this reason, it was not until 1997–1998 that efforts to equalize health care access were implemented through national maternal and child health care programs. A public health insurance program for vulnerable populations and those in poverty, SIS-MINSA, was implemented in 2002, expanded in 2009–2010 within a UHC initiative, and further expanded by a 2019 decree affiliating all uninsured residents within SIS-MINSA [13]. The health system nonetheless remains fragmented, with 70% of the population covered by SIS-MINSA, 20% covered through the Social Security System (ESSALUD) through the Ministry of Labor, and small fractions covered through the armed forces and police and the private sector [14]. Health care services are provided separately within each of these sectors. This fragmentation informs the factors that foster corruption, such as weak regulatory oversight in healthcare facilities and personnel, complex bureaucratic procedures and excessive paperwork, lack of transparency in procurement processes for medical supplies and equipment and, one of the most harmful factors, the existence of a culture of impunity, in which the corrupt are not held accountable [15].

A precursor to accountability is accurate measurement [8]. However, measurement of forms of corruption such as informal payments is not yet standardized [16]. While multiple definitions of such payments have been proposed, a systematic review [17] recommends, “a direct contribution, which is made in addition to any contribution determined by the terms of entitlement, in cash or in-kind, by patients or others acting on their behalf, to health care providers for services that the patients are entitled to” [2] as the most clear and neutral definition. Operationalizing services to which patients are entitled in a specific health system is essential to capturing informal payments.

Informal payments in healthcare can occur at various points during user’s care process. This could involve offering under-the-table payments to healthcare providers in exchange for faster or more favorable treatment. Also, patients could pay to shorten waiting time or bypass queues at services, to obtain medicines or medical supplies in short supply, or to accelerate access to surgical services. In some cases, those payments take the form of gifts or non-monetary goods, which may come from people who are not necessarily sick, but who need other types of services such as falsification of medical documents [18–20]. Informal payments have important repercussions on the accessibility of health services, especially for the population living in vulnerable situations. A prior study in 33 low-income countries in Africa found informal payments provided an advantage to those with more resources and hence exacerbated disparities in access to health care between poor and rich as well as disparities between regions [21].

Understanding the prevalence of informal payments, their distribution across health services, and the factors associated with making such payments is an important step in ensuring accountability within health systems and improving the quality and equity of health care services. Measurement approaches to understand informal payments include both qualitative and quantitative methods, particularly household survey records and corruption surveys. For instance, in Peru, a 2018 study estimated the prevalence of informal payments in users of the SIS-MINSA public health insurance from 2008 to 2010 using information collected in the National Household Survey of Living Conditions and Poverty (ENAHO). This study found a prevalence of expenditures outside the tariff framework and during the health care process in all 25 regions of the country. It was also shown that the frequency of SIS-MINSA users who made these payments at some point during their process of care increased from 27% in 2008 to almost 35% in 2010 [22]. Since this time, ENAHO has added modules particularly focused on the evaluation of the population’s experience with government/public entities to assess governance directly asking for bribes or illegal situations.

In this study, we aim to describe prevalence of informal payments in public health services in Peru following the expansion of public health coverage, to identify the types of health services where informal payments are most prevalent, and to characterize individual health care users most susceptible to informal payments.

Methods

Results

Of the 39,820 households sampled, ENAHO surveyed 132,355 people. Within them, 69,839 (52.80%) were affiliated to SIS-MINSA and 30,461 (23.03%) to ESSALUD (Table 1). The population covered by SIS-MINSA was poorer and more rural than ESSALUD affiliates (32.56% vs 5.71% in poverty, p<0.001, and 36.80% rural vs. 4.65%, p<0.001). In addition, ESSALUD affiliates were more likely to have completed undergraduate education (36.23% ESSALUD vs. 9.53% MINSA p<0.001).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Demographics characteristics of ESSALUD and SIS-MINSA user’s.

https://doi.org/10.1371/journal.pgph.0001837.t001

To evaluate the prevalence of informal payments according to the direct approach, we considered the response of the heads of household who also had public health insurance, so we analyzed the data of 3,964 insured in ESSALUD and 11,458 in SIS-MINSA. The prevalence of informal payments was 0.42% within ESSALUD and 0.22% within SIS-MINSA (Fig 1) using the direct approach.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Prevalence of informal payments in ESSALUD and SIS-MINSA ‐ direct method approach.

https://doi.org/10.1371/journal.pgph.0001837.g001

Over 99% of respondents from both ESSALUD and MINSA reported neither being asked nor providing informal payments. Among ESSALUD affiliates, 0.56% reported being asked for an informal payment (of whom 41% provided one) and 0.19% of patients reported making informal payments even when not asked to do so by staff or providers. A similar trend was observed among SIS-MINSA affiliates, with 0.64% asked for an informal payment (and 22% providing one) and only 0.08% of SIS-MINSA patients making informal payments without being prompted to do so during their care.

Using the indirect method of reporting cost for a service that should be no-cost, (Fig 2) within SIS-MINSA services, the highest prevalence of informal payments made for users in the last year occurred during in-patient services (17.37% of SIS-MINSA users, 4.11% of ESSALUD users) and surgical intervention (10.86% within SIS-MINSA, 1.11% within ESSALUD).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 2. Informal payments prevalence in ESSALUD and SIS-MINSA health services ‐ indirect method approach.

https://doi.org/10.1371/journal.pgph.0001837.g002

We characterized the population that most affected in services with prevalence of informal payments > 4%. We found that within the SIS-MINSA hospitalization services, those who are not in poverty and who live in urbanized areas were the ones who had made informal payments during their care process (Table 2). We did not identify statistically significant differences in characteristics of ESSALUD patients reporting and not reporting informal payments.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Sociodemographic characteristics of population in high-reported informal payments health services.

https://doi.org/10.1371/journal.pgph.0001837.t002

Discussion

The present study analyzed the prevalence of informal payments within those covered by public health services in Peru through a direct method and an indirect method. We found that, when asked directly, the prevalence of informal payments was very low, less than half a percent in each sector. However, using the indirect method, the reporting percentages were much higher, especially in the in-patient service (MINSA: 17.37%, ESSALUD: 4.11%) and surgical intervention (MINSA: 10.86%; ESSALUD: 1.11%). Our analysis of individuals making informal payments in these services revealed a statistically significant relationship between such payments and two characteristics: urban residence and a classification as non-poor based on their living conditions.

Our results suggest a decline in prevalence compared to the analysis of the 2010 national study [22]. It is possible these results suggest a true decline in informal payments over time, given the expansion of social security and the broader availability of affordable services in the public health system. However, the difference may also be related to changes in measurement: although both analyze informal payments with almost the same set of questions from the cross-sectional national survey ENAHO, the survey in 2010 and 2018 version has changed such that 2010 items focus on the service/product received in the previous 4 weeks and include details on the type of facility and professional interacting with the patient. The 2018 survey used a range of recall periods across health services and did not include details on the health personnel or the type of facility.

The extremely low prevalence of informal payments reported directly is a striking finding. Within the same nationally representative survey, individuals who were directly asked about informal payments reported a much lower frequency compared to those who only indicated that they had made payments while insured. This could reflect social desirability, in a context such as Peru, where corruption is widespread and social norms may conflict when asking about corrupt behavior or complicity in corrupt behavior [24]. In this sense, it’s suggested to generate data by selecting other strategies that reduce the discomfort of respondents when having to answer a sensitive question. It could be achieved using alternatives approaches of recollection of informal situations like the indirect method for informal payments, which take into consideration participants who attended public services and requested services which are free and fully covered by law but are willing to pay to obtain free access to full healthcare coverage and medications. Items that do not directly mention “informal”, “illegal” or “corruption” reduce the potential risk-perception to the respondents. A challenge in operationalizing informal payments is clarity on the benefits to which the patient is entitled free of charge [17]. Differentiating between informal payments and legitimate out-of-pocket payments may be difficult due to a lack of patients’ awareness of their legal rights and coverage entitlements. In that sense, it may be valid to assume that all transactions where patients report being not given any information about official co-payments rates or fees are informal [4, 25, 26]. Future efforts to measure informal payments may consider assessment of respondents’ awareness of entitlements and expected payments.

Services with higher prevalence of informal payments included in-patient care from both SIS-MINSA and ESSALUD, and surgical intervention within SIS-MINSA. Multiple factors may account for this finding. Users may be more motivated to pay for higher quality care for high acuity services than for primary care, particularly when such services are in short supply. A significant percentage of the Peruvian population lacks proper access to the health center of high level of complexity, leading to barriers in effective care delivery [27]. Inpatient services often involve more complex and specialized care and more specific resources and medications; they are less familiar to patients than routine primary care. These factors may lead to higher expectations from patients and a greater willingness to make informal payments [28, 29]. Although there is no evidence patients in Peru must buy their own supplies, this has been demonstrated in other countries which also face structural health systems issues. In those countries, patients or their relatives are required to contribute essential materials as medicines, medical supplies, injections, vaccines, diapers, and even non-medical supplies for their surgical intervention or their in-patient stay [30]. These factors create an environment where patients feel compelled to make informal payments to receive the care they need.

Within SIS-MINSA, less poor individuals and those in urban areas were more likely to make informal payments. Although more than half of the population is affiliated to SIS-MINSA, which is the insurance that covers those who are in a situation of vulnerability and who do not have other health insurance, this does not mean that affiliates are without sources of income with which they could pay for health care. According to the World Labor Organization, 75% of the workers in Peru are informal [31], so they would not have a social insurance granted by their employer, thus belonging to the SIS-MINSA. This means that within this insurance there are people who have economic resources, and although these resources may be limited, they could agree to make informal payments because these payments would be significantly lower compared to expenses in a private facility [26, 32]. Another possibility is that health care providers do not approach patients with limited resources for informal payments. Finally, some researchers have hypothesized that informal payments could lead to "redistribution" among users, with welfare/administrative staff playing a "Robin Hood" role, subsidizing the poor and charging the rich [21]. One of the assumptions for this to occur is that health care personnel represent a "collection agency for medical charities" that solicits the better off above marginal cost and uses the proceeds to provide care for the poorest. However, no studies to date have substantiated the idea that the poorest actually receive a benefit in access, quality, or satisfaction.

Supporting information