In the present study, 6 participants were physicians, 4 were hospital managers or CEOs, 4 were treatment or technical managers, 2 were nurses and 12 were patients or their companions (Table 1).
Table 1
Demographic characteristics of the study participants
| Study population | Interviewee | No. |
| Service providers | Doctor | 6 |
| Hospital CEO/ manager | 4 |
| Treatment manager/ technical assistant | 4 |
| Nurse | 2 |
| Service recipients | Patient | 12 |
Table 2 shows the amount of informal payments and the type of medical specialty to which the payment was made. A total of 40,200,000 Tomans was paid informally to various specialties during one year. Among the various specialties, obstetricians and gynecologists received the highest amount of informal payments.
Table 2
Data related to the amount of payment and type of specialty
| Name of the person | Sex | Amount of money (Tomans) | Specialty of the doctor |
| male | Female |
| First person | * | | 600000 | Obstetrics |
| Second person | | * | 7000000 | Orthopedics |
| Third person | | * | 18000000 | Cardiology |
| Fourth person | | * | 4000000 | Oncology |
| Fifth person | | * | 2500000 | Oncology |
| Sixth person | * | | 300000 | Obstetrics |
| Seventh person | * | | 2000000 | Orthopedic spine surgeon |
| Eighth person | * | | 2000000 | Neurology |
| Ninth person | * | | 2000000 | Maxillofacial surgery |
| Tenth person | * | | 500000 | Obstetrics |
| Eleventh person | * | | 800000 | General surgery |
| Twelfth person | * | | 500000 | Obstetrics |
| Total | 8 | 4 | 40200000 | |
The findings in Table 3 show the reasons for informal payments from the perspective of health care providers. In this section, the interviewees were asked questions about the reasons for receiving under-the-table payments. After analyzing the data, a total of 4 main themes and 23 codes were obtained.
Table 3
Reasons for informal payments from the perspective of health care providers and recipients in Iran
| Main theme | Codes |
| Economic factors | 1- Improper tariff valuation of services 2- Failure to increase tariffs proportionate to inflation 3- Lack of comprehensive participation of stakeholders in determining tariffs 4- Tariff inconsistency in the public, private and charity sectors 5- Failure to pay financial claims on time by insurance companies 6- Insufficient coverage of basic and specialized services by insurance companies |
| Socio-cultural factors | 1. Decreased social capital of the medical community among the people 2. Improving the quality of life 3. Incorrect comparison of providers' income levels with the income of doctors in other countries 4. Existence of a culture of gratitude and appreciation 5. Health as a priority for society 6. Pride of service recipients (luxury in receiving services) 7. Pride of service providers (merit in providing services) 8. Lack of attention to ethical-religious issues by both providers and recipients of services 9. Insufficient attention to teaching professional ethics at universities and the workplace |
| Service delivery challenges | 1- High professional skills of the doctor 2- Use of modern medical equipment 3- The difficulty of the medical profession and the lack of attention to the needs of the medical community during education 4- The monopoly of some doctors |
| Legal-political factors | 1- Inadequate monitoring by upstream organizations 2- Lack of strict rules 3- Difficulty of proving informal payments 4- Presence of stakeholders in management and policy making processes |
A-Economic factors
Economic factors were considered as one of the main causes of the prevalence of informal payments from the perspective of health service providers in the Iranian health system. After analyzing the data, this theme and its causes were categorized into 6 main causes as follows.
1- Improper valuation of service tariffs
Improper or unrealistic valuation or tariffing of services, both in the private and public sectors, from the point of view of health care providers, and especially the physicians participating in the study, results in higher informal payments to their colleagues. The providers were of the opinion that the tariffs had been increased with the implementation of the health system transformation plan, but it was still far from the actual amount.
“Medical expenses, i.e. low medical salaries, are one of the reasons why it may have existed from the beginning, and doctors consider their own salary higher than what is given to them in the government system. Therefore, they want to compensate this low income and the easiest way is to get under the table payments. (D-3)”
2- No increase in medical tariffs proportionate to inflation
As pointed out by health service providers, economic instability and high inflation in the country, not only in the health sector but also in other organizations and sectors, cause illegal and unconventional earnings due to compensation for lost income caused by inflation. One of the participants stated:
“One of the reasons for informal payments and in fact the reason for having it was the fixed medical and surgical tariffs despite the inflation rate. The medical salary, which is, for example, 38 thousand Tomans should be increased to 50 or 60 thousand Tomans. (A-7)”
3- Lack of comprehensive participation of stakeholders in setting tariffs
Weak involvement of stakeholders in the tariff process and excessive government interference in this process leads to unrealistic tariffs and this ultimately results in an increase in paying informal payments by patients. Such issue existed before the health transformation plan and still exists after the transformation plan and has become even worse.
“Government interference in tariff process, however, in most jobs that are not even related to doctors, is that, for example, you go to a mechanic, a pizza shop or a locksmith, they put a price tag there. Who sets this price tag?" "The guild and the union have done this. Almost all the guilds set the tariff themselves in proportion to what they do, while here the doctors themselves have little role in determining the price. )1-8(“
4- Not having the same tariffs in public, private and charity sectors
Participants cited unequal tariffs in public and private sectors, which lead to injustice, as one of the reasons for receiving informal payments. One of the participants said in this regard:
“I think another reason for receiving informal payments is the difference between the private and public sectors in terms of medical tariffs. As a result, the doctor who works in the public sector compares the tariff with the private sector and sees that this tariff is much lower than the private sector. This makes him either takes money from the patient for what he wants to do there, or direct the patient to the private sector, which has both higher tariffs and less supervision, and it is easier for him to take the money he wants from the patient. (A-11)”
5- Failure to pay financial claims on time by insurance companies
One of the main reasons for informal payments from the perspective of physicians and after the implementation of the health system transformation plan is the lack of timely payment by insurance organizations. Although this delay existed before the implementation of the transformation plan, from the people's point of view, this delay could not cause the expansion of informal payments in the health system.
“When a surgeon goes to the hospital in the middle of the night and operates on a patient, but he/she is paid a small fee a few months later, this will tempt the doctor to ask for informal payments. (A-2)”
6- Insufficient coverage of basic and specialized service packages by insurance companies
According to health service providers, lack of trust in insurance organizations, which is due to them not paying hospital claims on time and also providing inappropriate service packages, has led to the spread and expansion of informal payments before and after the health system transformation plan in Iran. With the implementation of the health system transformation plan, this cause has become more prominent than before. One of the participants said in this regard:
“If the insurance cards were valid and accepted in public hospitals, the patient would no longer be willing to give informal payments. In this case, the surgeons who receive informal payments should also look for the patient. (1-7)”
B- Socio-cultural factors
After interviewing the participants, socio-cultural factors were divided into 9 categories.
1-Decreased social capital of medical community among people
Some providers believed that due to excessive complaints from physicians, which cause physicians to spend their time resolving such issues, physicians are receiving informal payments to compensate for the costs incurred.
“People can complain about doctors in any way. Failure to do proper medical practice, even if the doctor is not to blame, is a way for people to complain and this is bad, because, with the current situation, every doctor is now trying to prevent from a problem. The doctor also tries to have a financial base that if someone complains, at least he can be held accountable. (A-4)”
Some providers also believed that the negative atmosphere created by negative media advertisements and programs would cause their colleagues to receive informal payments. Doctors said that when there is this unfair negative publicity and atmosphere and people do not have a good view of doctors, doctors unconsciously get affected by this atmosphere and behave in an unusual way.
“It may not be as widespread as the advertisements in the media. When there is a negative atmosphere against the doctors and people no longer trust and accuse us, well, my colleagues say, now that whether we receive informal payments or not, this atmosphere against us won't change, so it's better to receive it, and this is why they get informal payments from the patients and this atmosphere gets worse every day. (A-5)”
2- Improving the quality of life
Some providers receive informal payments because of their higher quality of life, which is due to cultural problems in the community. Having a higher quality of life has always existed in other professions and organizations, but the reason and method of achieving it has been different. According to the providers, one of the reasons for having a higher quality of life is the society's excessive expectation of doctors' standard of living.
“In fact, we graduated after 12 or 13 years of education, and if we drive a simple car after this period, people will tell us that someone is driving a simple car after all these years of education, and this subconscious pressure will lead doctors to receive informal payments.(1-6)”
3- Incorrect comparison of providers' income levels with their counterparts in other countries
One of the issues raised by physicians that have led to receiving informal payments is the unintentional comparison of their income with that of physicians in other countries.
“Besides that is the comparison of Iranian doctors to doctors in other countries. They always compare themselves with other countries and when see the financial differences; they try to make it up through other ways. (A-15 )”
4- Existence of a culture of gratitude and appreciation
The culture of gratitude has always existed and will exist in the culture of our country, but its method will be different in different people. Some physicians believed that patients themselves made additional payments voluntarily in order to compensate for the physicians' efforts.
“I was talking to one of my colleagues who was saying, 'Why shouldn't I get the money. The patient came to me, I said that I want to operate on your knee, he said how much is it, Mr. Doctor? I said, for example, 4 million Tomans, he said you want to do it yourself or your student will do it for me. Then he said 4 million is very little. I will give you 10 million and if you do the operation well, I will give you 5 million more after the operation. (A-2)”
5- Health is a priority for society
Some providers argued that because some people may only get sick once in a lifetime, it is best to regain their health as best as they can, and therefore make illegal payments to achieve their goals at the request of a physician or of their own free will.
“I myself did not resist when I saw that the doctor wanted informal payments. How many times do I want to have children? I pay more but I am sure about the health of my wife and child. I was saying to myself what if I don’t pay this money and something happens to my wife and child. (D-6)”
6- Pride of service recipients (luxury in receiving service)
The existence of a culture of luxury in some recipients of services regardless of receiving quality services was another reason for the existence of informal payments in the Iranian health system. A culture called "competition" culture, which makes people in Iran refer to the famous doctors of the city, who are even famous for receiving informal payments, in order to show off their pride and power, and even voluntarily pay more money outside the defined framework.
“Unfortunately, there is this culture of competition in our country. We had a relative whose wife wanted to give birth to a child in the famous hospital of the city and by a very famous doctor. He himself knew that the doctor would take under the table payments too much, but because his wife had said that I must go to that doctor, he had to take her there and had to pay a lot of money as well. (D-7)”
7- Pride of service providers (merit in providing services)
There is a culture of merit among health system providers in order to increase the value of services and show the quality of services provided by them, which leads to receiving informal payments from the clients.
“Another problem is that many of our doctors take bribes to attract customers. You may say what do I mean? I will explain. You see, some of our doctors, many of whom are professors, open their offices in luxurious and expensive places in the city and then try to say that our work is very good and that we are skilled so you have to stay in waiting list and if you want to operate, you have to go to a private hospital. There, you have to pay some money to the hospital and also I get a certain amount of money for the operation (P-11).”
8- Lack of attention to ethical-religious issues by both providers and recipients of services
Considering the religious conditions of Iran and the fact that many religious authorities have forbidden receiving informal payments by doctors, this issue was reflected in the findings of the present study. According to some providers, due to the weak religious beliefs that exist in some providers and lack of adherence to religious principles, they easily receive informal payments. One of the providers stated:
“In my opinion, if a doctor has a basic belief, he will not do it. If a doctor has a religious basis, from a religious point of view, he/she does not do this, but if they do not have a belief, they do so easily. Some of the worst kinds, in my opinion, are those who accept morality and religious issues but justify themselves and justification is something that I, as a physician, may inadvertently have the same justification for the next ten years and think that I am doing my work and it is not wrong, but when I go back and look from the outside, I see that it is informal payment”. (A-5).
9- Insufficient attention to teaching professional ethics at universities and the workplace
According to the providers, lack of training or poor ethics training in medical courses at university, and choosing the wrong role models by physicians are one of the main reasons for receiving informal payments.
“So far, I have not heard anything from any professor about whether to take informal payments or not, but we have heard this many times that the tariffs and fees of a doctor are low, and most of us look at the performance of those professors, professors or anyone else have a different perspective. Someone takes a teacher as a role model and treats like them. (A-6)”
C- Service delivery challenges
This theme includes four reasons for having informal payments as well as items related to the methods of treatment and unbalanced distribution of physicians in different places.
1- High professional skills of the doctor
The providers believed that the skills of physicians in their work would cause them to receive informal payments.
“For example, a doctor who is very knowledgeable in heart surgery says, "Why should I get the same amount of money like a usual heart surgeon who is not skilled in his/her work one tenth of me?" I worked so hard and have done many surgeries to get here, but I still have to get the same amount of money like a typical surgeon who has just started and it is not clear what he/she will do. (A-13)”
2- Use of modern medical equipment
Using various treatment methods was mentioned as one of the reasons for having informal payments in the Iranian health system. The providers believed that the facilities and equipment that some physicians use in private offices or hospitals were up-to-date and available to a small number of people, and therefore considered the current approved prices to be unfair.
“In big cities, the costs are generally higher and their techniques and methods are also different, and these have an impact on receiving informal payments. When a doctor is using a medical device which is very expensive, he/she does the math and understands that his/her income doesn’t match the costs; therefore, they get more money from the service recipients. Well, these devices and equipment are usually used in big cities and places where people are rich, and the people there have no problem with the costs, so they give whatever the doctor wants. (D-8)”
3- The difficulty of the medical profession and the lack of attention to the needs of the medical community during their education
From the physicians' point of view, the difficulty and the length of studying medical courses are among the reasons for having informal payments in the Iranian health system.
“Well, some colleagues believe that we studied for so many years, stayed up so many nights, did not receive any money before graduation, and now we are 40 years old, and nothing can be done with these tariffs. After all this study, we have to go through hard night shifts again, stay on foot in the operating room for a few hours, and if there is a problem for the patient, we have to answer to everyone. When they look at this, they feel that they deserve more than this. (1-4)”
4- The monopoly of some doctors
The monopoly of some physicians, especially in deprived areas, and giving patients the right to choose is one of the main reasons for receiving informal payments before and after the health system transformation plan in Iran.
“In our city, the highest informal payments are received by the medical group, who are 2 doctors in the whole city, so the supply limit is very important. But in a field where there are 10 or 15 specialists in the city, the proportion of informal payments decreases to the same extent .(1-9)”
D- Legal - political factors
Participants in this part of the study pointed out four legal and political reasons to be effective in promoting and prevailing informal payments in the Iranian health system.
1- Inadequate monitoring of upstream organizations
Most of the participants in the study believed that poor monitoring, both in the past and now, was one of the main reasons for the formation and prevalence of informal payments in the Iranian health system.
“The issue of monitoring is very important and effective here, and I think that one of our serious problems is the gaps in monitoring of and dealing legally with violators. (A-10)”
2- Lack of strict rules
The findings of the present study showed that the lack of strict and deterrent laws before and after the implementation of the health system transformation plan has caused having informal payments in the Iranian health system. Most people believed that the laws became stricter after the implementation of the health system transformation plan, but it still does not have enough deterrence to eliminate the phenomenon of informal payments in Iran.
“My many years of experience in this field show that we have no effective mechanism to deal with the phenomenon of under the table. In your opinion, now if one of my colleagues takes informal payments and it is proven, what will happen.(1-8)”
3- The difficulty of proving the receiving of informal payments
Another reason for the prevalence of informal payments in the Iranian health system is related to the difficulty of proving it, which remains in force even after the implementation of the health system transformation plan.
“Proving that the provider asked the service recipient for informal payments is a difficult issue for the person who gave it; for example, you have to prove that you gave informal payments and the provider denies it. (A-9)”
4- Presence of stakeholders in management and policy-making processes
The presence of stakeholders and providers at the levels of management and policy making in the health system, as well as the political power and skills of some of them leads to receiving informal payments by them. One of the participants said:
“In my opinion, the health transformation plan has not been able to prevent this very much. For example, there are doctors who have a power of their own that they are not afraid of the consequences. I think such things happen behind the scenes. Iran Medical Council are all physicians and all of them support physicians, and the rest of them, who are either connected somewhere or do their job well enough that nobody can say anything to them, they get informal payments without any fear, and everyone knows that. (A-16)”