Implications for policy makers. Policies and programmes should also seek to improve working conditions by improving remuneration and moving away from cash transactions as highly acceptable interventions to reduce the chances for engaging in informal payments.
Informal payments compromise delivery of healthcare and the public can reasonably expect that authorities will prevent them. Health providers are amenable to measures that would do this but the package of measures should be adapted to the characteristics and preferences of the work force. Attempts to reduce informal payments should begin by identifying what strategies are preferred most by health providers, to design bottom-up approaches to maximize their acceptability.
Offering incentives for good behavior such as opportunity for private practice, better working environment, better remuneration, and career growth opportunities are highly acceptable to health workers and strongly preferred over measures that threaten punishment for breaches. Informal payments are common in health systems in many low- and middle-income countries. They include payments for care or for health supplies that are formally covered by the health system, made to individuals or institutional facilities, in kind or in cash, and are unregulated or illicit.
Traditionally, anticorruption research in the health sector has been dominated by frameworks that see rule-breaking including the levying of informal payments as a consequence of poor governance. Examples include creation of an independent authority to investigate and punish corruption, increasing awareness of the unacceptability of these practices among health workers and the public, paying health workers more, and enforcing disciplinary measures.
In particular, limited attention has been given to the ways in which various incentives affect health workers and institutions differently, and how each respond to them. Recent political economy frameworks developed to investigate rule-breaking in the public sector may offer a means to address this issue. The Anti-Corruption Evidence ACE research programme, 13 undertaken in Tanzania, Nigeria and Bangladesh, uses a political settlement framework to understand behaviour of actors in the health system.
