Journal of Medical Ethics and History of Medicine 2018. 11(0):.

Evaluation of informal payments to health care professionals and the influential factors in Urmia city hospitals, Iran
Abdolvahed Khodamoradi, Arash Rashidian, Reza Daryabeygi‐Khotbehsara, Siamak Aghlmand


Informal payments refer to sums that patients may pay to individual or organizational health care providers outside of the official payment channels or approved fee schedules. The aim of the current research was to investigate informal payments and related influential factors in Urmia city hospitals.

The present study was a cross-sectional survey conducted among post-discharged patients from all Urmia city hospitals during one Iranian calendar month (January 21 to March 19, 2013). Simple random sampling was used to recruit 265 patients to undergo assessment via phone call interviews and complete a questionnaire. Data analysis was performed using SPSS software for descriptive reports, and EViews software for determination of factors affecting informal payments.

Eleven percent of the patients had made informal payments to physicians (mean amount: 503,000 Tomans, equivalent of $412), 5% to nurses (mean amount: 20,000 Tomans, equivalent of $16), and 17% to other employees (mean amount: 16,000 Tomans, equivalent of $13). Hospital ownership, patients’ place of residence, education and income significantly influenced the payments. Most substantially, patients receiving surgical care were 100 times more likely to make informal payments compared to those who had received non-surgical inpatient care.

The present study showed that although informal payment is illegal in Iran, it is a common practice among hospitalized patients, and has now become a challenge for the health system. Considering the high prevalence of informal payments and their severe impacts on equity and justice, policymakers have focused on this phenomenon to reduce and eliminate it.


Out-of-pocket payment, Informal payment, Health care professionals, Iran

Full Text:



Ensor T. Informal payments for health care in transition economies. Soc Sci Med. 2004; 58(2): 237-46.

Lewis M. Informal payments and the financing of health care in developing and transition countries. Health Aff (Millwood). 2007; 26(4): 984-97.

Lewis MA. Who is paying for health care in Eastern Europe and Central Asia? USA: World Bank Publications; 2000.

Mæstad O, Mwisongo A. Informal payments and the quality of health care: Mechanisms revealed by Tanzanian health workers. Health policy. 2011; 99(2):107-15.

Ozgen H, Şahin B, Belli P, Tatar M, Berman P. Predictors of informal health payments: the example from Turkey. J Med Syst. 2010; 34(3): 387-96.

Roberts M, Hsiao W, Berman P, Reich M. Getting Health Reform Right: A Guide to Improving Performance and Equity. UK: Oxford university press; 2008.

Belli P, Gotsadze G, Shahriari H. Out‐of‐pocket and informal payments in health sector: evidence from Georgia. Health Policy. 2004; 70(1):109‐23.

Gaal P, Belli PC, McKee M, Szócska M. Informal payments for health care: definitions, distinctions, and dilemmas. J Health Polit Policy and Law. 2006; 31(2): 251-93.

Tomini S, Maarse H. How do patient characteristics influence informal payments for inpatient and outpatient health care in Albania: results of logit and OLS models using Albanian LSMS 2005. BMC public health. 2011; 11(1):375.

Gaal P, Evetovits T, McKee M. Informal payment for health care: evidence from Hungary. Health Policy. 2006; 77(1): 86-102.

Stringhini S, Thomas S, Bidwell P, Mtui T, Mwisongo A. Understanding informal payments in health care: motivation of health workers in Tanzania. Hum Resour Health. 2009; 7: 53.

Ensor T, Witter S. Health economics in low income countries: adapting to the reality of the unofficial economy. Health Policy. 2001; 57(1):1-13.

Khodamoradi A, Ghaffari MP, Daryabeygi‐Khotbehsara R, Sajadi HS, Majdzadeh R. A systematic review of empirical studies on methodology and burden of informal patient payments in health systems. Int J Health Plann Manage. 2017; 33(1): e26- e36.

Zakeri M, Olyaeemanesh A, Zanganeh M, et al. The financing of the health system in the Islamic Republic of Iran: a national health account (NHA) approach. Med J Islam Repub Iran. 2015; 29: 243.

Abolhallaje M, Hasani SA, Bastani P, Ramezanian M, Kazemian M. Determinants of catastrophic health expenditure in Iran. Iran J Public health. 2013; 42(1):155-60.

Rashidian A, Karimi-Shahanjarini A, Khosravi A, et al. Iran's multiple indicator demographic and health survey -2010: study protocol. Int J Prev Med. 2014; 5(5): 632-42.

Ghiasipour M, Poorreza A, Arab M, Mahmoodi M, Abutorabi A. The analysis of informal payments among hospitals covered under Tehran University of Medical Sciences (TUMS) 2009. Journal of Hospital. 2011; 10(3):9-22. [in Persian]

Parsa M, Larijani B, Aramesh K, Nedjat S, Fotouhi A, et al. Informal payment in Iran: a cross-sectional study prior to implementation of the health system reform. Medical Ethics and History of Medicine. 2017; 9(6): 34-46. [in Persian]

Vafaei Najar A, Ebrahimipour H, Pourtaleb A, et al. At first glance, informal payments experience on track: why accept or refuse? patients’ perceive in cardiac surgery department of public hospitals, northeast of Iran 2013. BMC Health Services Research. 2017; 17:205.

Aboutorabi A, Ghiasipour M, Rezapour A, Pourreza A, Asiabar AS, Tanoomand A. Factors affecting the informal payments in public and teaching hospitals. Med JIslam Repub Iran. 2016; 30: 315.

Amiresmaili M, Nekoeimoghadam M, Esfandiari A, Ramezani F, Salari H. Causes of informal payments in health sector: a qualitative study of viewpoints of physicians, policy makers and patients. Medical Ethics and History of Medicine. 2013; 6(3):72-83. [in Persian]

Parsa M, Aramesh K, Nedjat S, Kandi MJ, Larijani B. Informal payments for health care in Iran: results of a qualitative study. Iran J Public Health. 2015; 44(1):79.

Meskarpour-Amiri M, Arani AA, Sadeghi H, Agheli-Kohnehshahri L. Socioeconomic factors affecting informal payments in the health sector. Transylvanian Review of Administrative Sciences. 2016; 47:116-28.

Khodamoradi A, Rashidian A, Aghlmand S, Arab M. Informal Payments in Health Sector and Policies to Deal With (a review study). Journal of Hospital. 2015; 14(3): 23-32. [in Persian]

Liaropoulos L, Siskou O, Kaitelidou D, Theodorou M, Katostaras T. Informal payments in public hospitals in Greece. Health Policy. 2008; 87(1):72-81.

Stepurko T, Pavlova M, Gryga I, Groot W. Empirical studies on informal patient payments for health care services: a systematic and critical review of research methods and instruments. BMC Health Services Research. 2010; 10: 273.

Rizzo JA, Blumenthal D. Is the target income hypothesis an economic heresy? Medical Care Research and Review. 1996; 53(3): 243-66.

Kavosi Z, Rashidian A, Pourreza A, et al. Inequality in household catastrophic health care expenditure in a low-income society of Iran. Health Policy PlanP. 2012; 27(7): 613-23.

Aarva P, Ilchenko I, Gorobets P, Rogacheva A. Formal and informal payments in health care facilities in two Russian cities, Tyumen and Lipetsk. Health Policy Plan. 2009; 24(5): 395-405.

Arsenijevic JPM, Groot W. Out-of-pocket Payments for Health Care in Serbia. Health Policy. 2015; 119(10):1366-74.

Baji P, Pavlova M, Gulácsi L, Zsófia HC, Groot W. Informal payments for healthcare services and short‐term effects of the introduction of visit fee on these payments in Hungary. Int J Health Plann Mgmt. 2012; 27: 63-79.

Kaitelidou DC TC, Galanis PA, Siskou OC, et al. Informal payments for maternity health services in public hospitals in Greece. Health Policy. 2013; 109(1): 23-30.

Tengilimoğlu D, Güzel A, Toygar A, Akinci F, Dziegielewski SF. Informal Payments in Health Systems: Purpose and Occurrences in Turkey. Journal of Social Service Research. 2015; 41(5): 684-96.

Gordeev VS, Pavlova M, Groot W. Informal payments for health care services in Russia: old issue in new realities. Health Econ Policy Law. 2014; 9(01): 25-48.

Paredes-Solís S, Andersson N, Ledogar RJ, Cockcroft A. Use of social audits to examine unofficial payments in government health services: experience in South Asia, Africa, and Europe. BMC Health Ser Res. 2011; 11(Suppl 2): S12.

Stepurko T, Pavlova M, Gryga I, Groot W. To pay or not to pay? a multicountry study on informal payments for health‐care services and consumers’ perceptions. Health Expect. 2015; 18(6): 2978-93.

Atanasova E, Pavlova M, Moutafova E, Rechel B, Groot W. Out-of-pocket payments for health care services in Bulgaria: financial burden and barrier to access. European Journal of Public Health. 2013; 23(6): 916-922.

Tomini S, Groot W, Pavlova M. Informal payments and intra-household allocation of resources for health care in Albania. BMC Health Services Research. 2012; 12:17.

Tambor M, Pavlova M, Golinowska S, Sowada C, Groot W. The formal–informal patient payment mix in European countries. governance, economics, culture or all of these? Health Policy. 2013; 113(3): 284-95.

Ensor T, Thompson R. Health insurance as a catalyst to change in former communist countries? Health Policy. 1998; 43(3): 203-18.

Vian T, Burak LJ. Beliefs about informal payments in Albania. Health Policy Plan. 2006; 21(5): 392-401.

Balabanova D, McKee M. Understanding informal payments for health care: the example of Bulgaria. Health Policy. 2002; 62(3): 243-73.


  • There are currently no refbacks.

Creative Commons Attribution-NonCommercial 3.0

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.