Out-of-pocket payments for health care in Serbia

Health Policy 119 (2015) 1366–1374

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Out-of-pocket payments for health care in Serbia Jelena Arsenijevic a,∗ , Milena Pavlova a , Wim Groot a,b a Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands b Topinstitute Evidence-Based Education Research (TIER), Maastricht University, The Netherlands

a r t i c l e

i n f o

Article history: Received 28 October 2014 Received in revised form 2 March 2015 Accepted 19 July 2015 Keywords: Informal patient payments Serbia Payments for “bought and brought goods”

a b s t r a c t Background: This study focuses on out-of-pocket payments for health care in Serbia. In contrast to previous studies, we distinguish three types of out-of-pocket patient payments: official co-payments, informal (under-the-table) payments and payments for “bought and brought goods” (i.e. payments for health care goods brought by the patient to the health care facility). Methods: We analyse the probability and intensity of three different types of out-of-pocket patient payments in the public health care sector in Serbia and their distribution among different population groups. We use data from the Serbian Living Standard Measures Study carried out in 2007. Out-of-pocket patients payments for both outpatient and inpatient health care are included. The data are analysed using regression analysis. Results: The majority of health care users report official co-payments (84.7%) and payments for “bought and brought goods” (61.1%), whereas only 5.7% health care users declare that they have paid informally. Regarding the regression results, users with an income below the poverty line, those from rural areas and who are not married are more likely to report payments for “bought and brought goods, while young and more educated users are more likely to report informal patient payments. Conclusion: Overall, the three types of out-of-pocket payments are not correlated. Payments for “bought and brought goods” take the highest share of the total annual household budget. Serbian policymakers need to consider different strategies to deal with informal payments and to eliminate the practice of “bought and brought goods”. © 2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Studies on out-of-pocket payments for public health care services often make a distinction between formal (official) co-payments and informal (under-the-table) payments [1,2].

∗ Corresponding author at: Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. Tel.: +31 043 388 1831. E-mail address: [email protected] (J. Arsenijevic). http://dx.doi.org/10.1016/j.healthpol.2015.07.005 0168-8510/© 2015 Elsevier Ireland Ltd. All rights reserved.

The latter type is defined as including not only informal cash payments and in-kind gifts but also payments for goods (e.g. pharmaceuticals, materials, equipment, bed linen and meals) that the patient or patient’s family are requested to bring to the health care facility (payments for “bought and brought goods”) [2]. A drawback of the above definitions is that they do not make distinction between the two types of informal patient payments: payments for goods brought by patients to the health care facilities and pure informal payments: cash and presents given in kind. We find it essential to make a distinction between these two types of patient payments because they differ in nature (see Fig. 1). While pure informal patient payments (such

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Fig. 1. Types of out-of-pocket payments is Serbia.

as gifts to the physicians) remain unregistered, payments for “bought and brought goods” (e.g. for pharmaceuticals bought in pharmacy and brought to the hospital) are officially registered at the point of purchase but usually not visible in the financial flows of the institution that provides the services. Informal patient payments are usually regulated by law (they can be illegal and forbidden by law like in Serbia or legal and not forbidden or even permitted by law like in Hungary), while there is no clear government regulations related to payments for “bought and brought goods” [3,4]. Given their registered but shadow nature, these payments for goods may be easily overlooked by policy-makers as long as they do not breach any laws and regulations. Although informal patient payments are widely spread and also widely studied in different parts of the world, e.g. in Central and Eastern Europe (CEE) [2,5–15], in southEuropean countries [16,17], in Asia [18,19], South America [20] and in Africa [21], the evidence related to payments for “bough and brought goods” are rare [3,7]. The previous literature has elaborated on informal patient payments describing the different strategies for their mitigation in different governmental, economic and cultural settings [7]. Furthermore, results from previous studies related to informal patient payments show that these payments can affect various population groups. For example, in Albania informal patient payments were more observed among low income groups [22], while in Russia and Israeli, informal patient payments are more often reported among high educated and high income groups [9,23]. Informal patient payments are observed in both inpatient and outpatient care, with higher amounts paid in inpatient settings [6,9,14,22] particularly in surgery and maternity wards [24]. The relation between informal patient payments and official (formal) co-payments has also been addressed in previous studies. In many countries, informal patient payments remain to exist even though official co-payments are introduced [6,25,26].

However, evidence specifically related to payments for “bought and brought goods” are rare. Although those payments were recognised as quasi-informal payments in some previous studies [9,27], they are rarely examined separately from other types of informal patient payments. Thus, their scope and scale are largely unknown. Nevertheless, if payments for “bought and brought goods” are frequent, they might substantially increase the burden of out-of-pocket payments for the patient and their household. Furthermore, neglecting the payments for “bought and brought goods” can lead to underestimation of the total out-of pocket patient payments. This study aims to fill this gap by examining the intensity and the extent of payments for “bought and brought goods”, as well as formal (official) and pure informal payments from the perspective of the Serbian public health care system (thus, excluding payments in the private health care sector). This system presents an interesting case due to the parallel existence of official co-payments, informal patient payments, as well as payments for “bought and brought goods” [28]. Detailed information about the Serbian public health care system can be found elsewhere [29]. Briefly, compulsory health care insurance has existed since the period of ex-Yugoslavia and since 2002 it has been accompanied by official co-payments. The size of the official co-payment depends on the type of service and it varies between approximately 1 USD (e.g. for a referral) and 551 USD (e.g. for cataract intervention). According to Serbian health care regulations, goods like disposable materials and pharmaceuticals for inpatient care should be provided for free [30]. Also, the maximum annual co-payments by a patient (excluding payments for disposable materials and pharmaceuticals that are not on positive list) may not be higher than one third of the patient’s salary or the patient’s average net annual income [30]. Informal patient payments are strictly forbidden in Serbia [31,32]. On the other side payments for “bought and brought goods” are accepted by policy

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makers in Serbia [33–37], and are not officially forbidden [32]. This study is not only of particular importance for Serbia. Recent studies in CEE countries show that the probability and the amounts paid for pure informal patient payments have been decreasing in the last decades [22]. One of the reasons is the stricter legislation on informal patient payments. On the other side, payments for “bought and brought goods” are more often reported in those countries [3]. This raises the concern that pure informal patient payments (illegal) can be replaced with quasiformal and semi-legal payments like payments for “bought and brought goods”. We use household-level data from the Living Standards Measurement Survey (LSMS) for Serbia carried out in 2007, i.e. 5 years after the recent health care reform started. The data are analysed using regression analysis (statistical package STATA 8). 2. Methods and data description The LSMS data for Serbia are collected under the supervision of the World Bank in 2007 [38]. The sample consists of 17,375 respondents living in 5557 households. The sample covers 98% of the total population in Serbia and is considered representative [38]. Data were collected by the Statistical Office of the Republic of Serbia using a stratified sampling method. The dataset consists of nine different modules including a health module that includes variables regarding health care spending of household members for hospitalisation, pharmaceuticals, and diagnostics in public inpatient units during the last 12 months and variables on household spending on physician visits, pharmaceuticals, and diagnostics in outpatient public health care units during the last month. A distinction is made between official co-payments (a fee paid by the patient for a physician’s visit, in accordance with the current regulation, a patient receives a bill for the services paid for), informal payments (money given to the physician in an envelope to secure faster and better care or presents like perfume, picture, alcohol drinks given to the physicians as a token of gratitude for services provided) for both outpatient and inpatient care, and out-of-pocket payments for “bought and brought goods” (pharmaceuticals that should be available in the hospital, usually necessary for the treatment, bought by the patient or his family on the physician’s request) in case of hospitalisation only. Data for payments for “bought and brought goods” for outpatient care are not available. All questions related to out-of-pocket patient payments are presented in Appendix 1. Since patients in Serbia are not supposed to bring goods for their hospitalisation, we assume that payments for “bought and brought” have a quasi-informal nature as defined by Stepurko [24]. This means that the goods are officially purchased by the patients or their families but the fact that they are brought to the hospital is against official regulation. Direct payments to health care providers for goods that should be provided for free, are treated as informal payments. The dataset does not provide any indication of which particular pharmaceutical or diagnostic procedure has

been paid for. Based on variables in the health module of the dataset, we have created four variables that specify respectively the total out-of-pocket patient payments, total official co-payments, total informal payments and total payments for “bought and brought goods” per health care user during the last 12 months. The data for outpatient care are based on a re-call period of one month and the data for inpatient care use a re-call period of 12 months. Therefore, we have multiplied the payments for out-patient care by 12 to obtain an annual estimate comparable to the data for inpatient care. We do not exclude the possibility that the method used for annualising the costs can lead to over- or under-estimation, but it is still widely advised and applied. Although annualised costs can lead to overestimation, they are still widely advised and applied [39]. Total out-of-pocket patient payments include official, informal and “bought and brought goods” payments for health care. Official co-payments include the payments related to physician visits and/or nurse interventions, laboratory tests, ultrasounds, referrals, hospital services and other services but also transport costs and extra accommodation costs known as indirect medical costs. Informal payments include the amounts that are given to physicians and/or nurses on their request or as a gift. The payments for “bought and brought goods” include the payments for pharmaceuticals and/or disposable and orthopaedic materials that the patient brought to the hospital and that should be provided for free by the hospital. Descriptive statistics are presented for each type of payments for both outpatient and inpatient services. We make a distinction between outpatient and inpatient services based on previous literature [6,14]. Furthermore, we examine the probability of payment and the amounts paid for official co-payments, payments for “bought and brought goods” and informal patient payments. For this purpose we run three sample selection models for the three separate types of payments: official co-payments, payments for “bought and brought goods” and informal patient payments. The first part of the model also known as the selection equation, uses a binary outcome variable (e.g. official co-payments yes = 1; no = 0), while the second part uses linear regression to model the amount paid officially, if the binary outcome is higher than 0. The selection equation assumes that the probability to pay is determined by a latent variable. We use the variable living in an urban/rural area as identifying variable for all three types of out-of-pocket patient payments. We apply the same sample-selection model for informal patient payments and payments for “bought and brought goods”. As independent variables, based on previous studies [26,40,41], we include socio-demographic variables (gender, education, marital status, settlement, work status and household size) as well as binary variables regarding the presence of different chronic diseases (asthma, cardio-vascular diseases, diabetes mellitus, hear and speech disorders etc.). We expect that some of the independent variables like people with chronic diseases (more frequent use of health care services) report more often all three types of payments [9]. Also, we expect that people living in urban areas, women and people with good perceived health have a lower probability to report any

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types of out-of-pocket patient payments [14]. The full list of independent variables is provided in Appendix 1. In order to solve the problem of a skewed data distribution, we use a logarithmic transformation for variables related to paid amounts for all three types of payments. We also present results from OLS regression related to the amount paid for all three types of out-of-pocket patient payments. We also estimate the share of the three types of out-of-pocket patient payments in the household annual consumption. For this purpose, we divide the annual amount of each type of payment reported by a health care user, by the annual household consumption per household member for that health care user. We present the results in a form of a cross-tab using 10% threshold and consumptionbased quintiles. 3. Results Nearly 29% of the respondents made use of health care during the past twelve months. Among health care users, 93.9% report some type of payments for public health care services (i.e. official co-payments, informal payments and/or “bought and brought goods” payments). The majority of health care users report official co-payments (84.7%) and payments for “bought and brought goods” (61.1%), whereas only 5.7% health care users declare that they have paid informally. Among payers, the average amount that is paid for “bought and brought goods” per year is higher than the official payments and the informal payments. Table 1 also presents data for payments for outpatient care and payments for inpatient care. As suggested by the table, informal payments are more frequent in case of inpatient services (10.9% of all payers for inpatient care reported informal payments) than in case of payments for outpatient care (≈2% of all payers for outpatient care reported informal payments). Payments for “bought and brought goods” for outpatient services are not measured in the Serbian LSMS 2007. Our additional analysis (not presented in the tables) suggests that the three different types of payments are not strongly correlated, neither in terms of incidence (Kendall’s tau < 0.1) nor in terms of amounts (Pearson correlation < 0.1). Also, 2783 (55.9%) health care users have reported two different types of payments and 193 (3.8%) health care users have reported all three types of payments. Table 2 presents the annual amount of each type of out-of-pocket patient payments as a share of the annual household consumption per household member. As suggested by the table, payments for “bought and brought goods” present the highest share in the annual household consumption per household member. Also, we observe that the burden of official co-payments for the 10% threshold is highest among the third consumption-based quintile, while for “bought and brought goods” payments the burden is highest among the second consumption-based quintile. For informal payments, this burden is minor for all quintiles Table 3 presents the results of the selection model (known as Heckman model) for three types of out-ofpocket patient payments. The probability to report official co-payments and payments for “bought and brought

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goods” is higher among participants with a chronic disease (asthma, cardiovascular diseases, diabetes and progressive diseases). Participants with lower perceived health report more often all three types of payments. On the other side, participants living in urban areas (0.19; p ≤ 0.05) have a higher probability to report official co-payments while participants living in rural areas (−0.08; p ≤ 0.05) have a higher probability to report payments for “bought and brought goods”. The probability to report informal patient payments is higher among those who are better educated, younger, living in urban areas and working. Results from the second stage regression show that among those who paid officially, higher amounts are reported by those who are unemployed and should be exempted from such type of payments. In case of participants who report payments for “bought and brought goods” higher amounts are paid by patients diagnosed with progressive diseases and higher educated. Amounts paid informally are lower in larger households, while higher amounts are reported among those diagnosed with asthma. Respondents from non-poor households more frequently report all three types of payments. Table 4 presents the results of the three OLS models related to the amounts paid for three types of payments. The regression analysis includes participants who paid for certain type of services. Our results show that payers with lower perceived health, report higher amounts for official co-payments and payments for “bought and brought goods”. Higher amounts for informal patient payments are reported by payers with diagnosed asthma. Results from OLS are similar with those from sample selection model. 4. Discussion and conclusions In this study, we distinguish three types of out-ofpocket patient payments in the Serbian public health care sector: official co-payments, payments for “bought and brought goods” and informal payments. We analyse the level of these types of payments among different sociodemographic groups in Serbia. Given the available data, we operationalise patient payments for “bought and brought goods” as the costs for pharmaceuticals and/or disposable materials and nonmedical goods that the patient or the relatives brought to the hospital. Our results show that official co-payments and payments for “bought and brought goods” present a relatively significant proportion of out-of-pocket payments in Serbia while pure informal payments are somewhat less frequent (only 5.7% of all health care users). Furthermore, the share of payments for “bought and brought goods” are higher than the share of informal and official co-payments in the annual household consumption. The explanation for the high share of patient payments for “bought and brought goods” in Serbia can be found in the nature of these payments. Goods that are requested by medical doctors are very often necessary for medical treatment, and it is less possible to ignore bringing these goods than to pay the informal patient payments. Also, both patients and providers might perceive payments for “bought and brought goods” differently from informal payments, for example view them as less problematic from an ethical

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Table 1 Descriptive statistics per type of payments. Types of payments

% of users reporting the payment type

% of payers reporting the payment type

Payment size based on payers Mean (SD)a

Payments for outpatient and inpatient care 84.7 Official co-payments 61.1 Payments for “bought and brought” goods Informal patient payments 5.7 Payments for outpatient care Official co-payments Official co-payments for physicians visit Official co-payments for pharmaceuticals Official co-payments for laboratory analyses Official co-payments for disposable materials Official co-payments for transport Informal patient payments Money requested by medical staff Gifts given to medical staff Payments for inpatient care Official co-payments Official co-payments for hospitalisation Official co-payments for pharmaceuticals Official co-payments for laboratory services Official co-payments for disposable materials Official co-payments for transport Payments for “bought and brought” goods Payments for pharmaceuticals brought by patient Payments for disposal materials brought by patient Payments for orthopaedic materials brought by patient Informal patient payments Money requested by medical staff Gifts to medical staff

90.1 65.0

5188.8 (11,683.8) 11,739.1 (21,446.6)

6.1

85.3 59.7

90.5 63.3

45.2

47.9

16.4

Min.a

Max.a

6.25 20

144,720 291,600

4914.4 (15,957.7)

25

128,000

5293.7 (11,890.6) 42.2 (147.8)

24 20

144,720 3000

232.6 (440.5)

10

5000

17.4

1044.7 (1743.9)

20

20,000

19.8

11.5

961.7 (1215.7)

20

9000

23.7

25.1

515.0 (743.3)

20

12,000

1.7 0.23

1.8 0.24

1060.1 (3676.7) 1256.8 (1887.5)

25 25

32,000 5000

1.55

1.6

1030.1 (3886.4)

50

32,000

72.8 48.2

77.1 51.0

5093.7 (9856.2) 3918.8 (8789.3)

6.25 15

22.1

23.3

2398.7 (4738.9)

50

50,000

2781.8 (4662.7)

25

40,000

12.1

(12.8)

102,000 100,000

6.8

7.2

8534.9 (11,449.3)

40

50,000

38.2

40.4

971.8 (1600.5)

20

20,000

22.7

24.1

2316.5 (5293.8)

60

55,000

19.9

21.0

1621.1 (2920.9)

60

30,000

1.9

2.11

4540.5 (7259.1)

150

25,000

2.8

2.9

4120.3 (7695.3)

100

30,000

10.4 0.4

10.9 0.4

5071.1 (10,361.5) 19,000 (16,452)

50 4000

80,000 40,000

10.1

10.7

4497.6 (9568.7)

50

80,000

point of view. One of the reason that patient do not perceive “bought and brought goods” payments problematic from ethical point of view, is that the payments for “bought and brought goods” have their roots in the times when the health care settings lacked medical materials, supplies, and pharmaceuticals due to a financial crisis [42]. In such circumstances, medical staff would ask the patient and/or relatives to bring supplies and pharmaceuticals that are necessary for the treatment but the hospital cannot provide due to poor funding [10]. From the perspective of patients and their families, this request is perceived as an act of cooperation and extra attention on the side of the health care provider rather than corruption. Furthermore, patients and their families might expect that by buying and bringing goods like medicine that are not available in the hospital, they will secure better quality of care [3,26,33]. At first

glance, such request is not interwoven with benefits to the health care providers and at the same time it is important for the curative process. In practice however, “bought and brought goods” can generate additional benefits for health care providers in several manners. For example, hospital staff may still declare the use of supplies and pharmaceuticals (even though these are brought by the patient) and can sell the “saved” medical goods on the black market, or use the “saved” goods in their private practices, or simply divide the money claimed for these goods in the form of an extra bonus. Such situations have been mentioned in research articles but the evidence for their existence is sparse and therefore, anecdotal [43]. Additionally, our regression results show that younger participants with a higher education have a higher probability of paying informally.

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Table 2 Annual payments as a share of the annual household consumption per household member (health care users). Consumption-based quintiles

a

All health care users

Poorest quintile N (% within quintile)

2 N (% within quintile)

3 N (% within quintile)

4 N (% within quintile)

Richest quintile N (% within quintile)

Total payments 0% health care expenditure More than 0% up to 10% More than 10%

76 (8.4) 696 (76.7) 135 (14.9)

58 (5.7) 813 (80.3) 142 (14.0)

49 (4.7) 832 (80.0) 159 (15.3)

61 (6.1) 810 (80.8) 132 (13.2)

58 (5.7) 814 (80.4) 141 (13.9)

302 (6.1) 3965 (79.7) 709 (14.2)

Official co-payments 0% health care expenditure More than 0% up to 10% More than 10%

156 (17.2) 717 (79.1) 34 (3.7)

162 (16.0) 824 (81.3) 27 (2.7)

145 (13.9) 848 (81.5) 47 (4.5)

144 (14.4) 819 (81.7) 40 (4.0)

159 (15.7) 821 (81.0) 33 (3.3)

766 (15.4) 4029 (81.0) 181 (3.6)

Informal payments 0% health care expenditure More than 0% up to 10% More than 10%

882 (97.2) 24 (2.6) 1 (0.1)

967 (95.5) 46 (4.5) 0 (0.0)

994 (95.6) 46 (4.4) 0 (0.0)

937 (93.4) 66 (6.6) 0 (0.0)

912 (90.0) 97 (9.6) 4 (0.1)

4692 (94.3) 279 (5.6) 5 (0.1)

“Bought and brought goods” payments 0% health care expenditure 379 (41.8) 501 (55.2) More than 0% up to 10% 27 (3.0) More than 10%

385 (38.0) 581 (57.4) 47 (4.6)

386 (37.1) 612 (58.8) 42 (4.3)

402 (40.1) 571 (56.9) 30 (3.0)

396 (39.1) 576 (56.9) 41 (4.1)

1948 (39.1) 2841 (57.1) 188 (3.7)

N (% within all health care users)

Measured in CSD, 1 CSD = 0.0125 Euro.

Apparently, these health care users are more aware of the common practice of paying additionally for health services that should be provided for free. They apply the so called “do-it-yourself” approach described in the literature as alternative politics [23]. These alternative politics refer to situation when people are dissatisfied with current government policy, they take unilateral initiatives. This means that they obtain the desired services but in a way that is different from the way defined by government policy, i.e. in a semi-private way [23]. Thus, better educated people pay informally because they anticipate that government policy does not work and if they do not pay informally, they will not get adequate service. The limitations of this study are mostly related to the data. We use an existing dataset collected by others, which provides no information about the type of treatment or type of pharmaceuticals that patients pay for. Also, we do not have information about the obstacles related to the utilisation of health care. More precisely, we do not know if patients forego using services that they need because they cannot afford them. Furthermore, a recall period of 12 months is rather long and may lead to recall bias. Information regarding “bought and brought goods” payments is only available for inpatient care and we do not know which particular pharmaceuticals or type of disposable material has been brought and bought into hospital. Moreover, payments for “bought and brought goods” are reported not only by inpatient health care users, but also by household members. The latter group made “bought and payments” for others. Despite these limitations, the dataset provides a representative sample and information on official copayments and informal payments for health care, as well as on payments for “bought and brought goods”, which makes it particularly useful for our study. Our results show that there are respondents who report all three types of payments. These findings indicate that the

current health care policy regarding official co-payments is not efficient. Health care users who pay officially do not have a guarantee that they will receive the services which they officially pay for. In order to obtain adequate health care service, health care users are often forced to bring necessary goods and pay informally. It was argued that official out-of-pocket patient payments were introduced by Serbian government, to provide both better efficiency and better funding of the health care system. It was also estimated that official co-payments can prevent unnecessary of services but also act as additional source of financing for underfinanced health care system [29,44,45]. Recent studies [36,46] emphasise that official co-payments are very low in nominal amounts and therefore they do not contribute to the financial sustainability of the health care system. Since they are part of the official health policy, we do not question their existence here. However, Serbian policymakers should better regulate the system of patient charges. In particular, policymakers need to consider strategies for dealing with informal payments and eliminating the practice of “bought and brought goods”. These will be important policy measures to decrease the overall burden of out-of-pocket payments in Serbia. Despite the high share of payments for “bought and brought goods” (as indicated by our results), they are very often neglected by both researchers and policy-makers [33–35]. Moreover, recent results in other CEE countries show that even when the probability of informal patient payments has decreased, the purchase of medical supplies and pharmaceuticals that should be provided for free, continuous to exist [3]. The reason can be seen in the fact that in many countries pure informal patient payments are strictly forbidden, while payments for “bought and brought goods” are not fully regulated [3]. Since the public health care services in those countries are still poorly funded, payments for “bought and brought goods” can be a valuable source

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Table 3 Results of the Heckman selection model. Explanatory variables

Official copayments Amounta paid

Selection model B Gender Marital status Age

2 = female/1 = male 1 = married/0 = not married age in years

Educational level University 1 = yes/0 = no degree 1 = yes/0 = no Up to high school Work status Nationality Household size

Urban Perceived health Exempted groups Consumption per person Asthma and bronhospasm Cardiovascular disease Abdomen disease Diabetes Epilepsy Progressive disease Rheumatology disease Legs or feet disease Beck and neck disease Ophthalmology disease Mental illness Hearingspeech difficulties Constant N selected Athrho LR test of indep. eqns. (chi2 ) Wald chi2 (whole model) * ** a

1 = working/0 = not working 1 = Serbian/0 = other number of household members 1 = city/0 = rural from 1 = very good to 4 = very bad 1 = exempted/0 = notexempted 1 = more than absolute poverty line 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed

p ≤ 0.05. p ≤ 0.10. Amount paid are log transformations.

Informal patient payments

Payments for “bought and brought goods”

SE

SE

SE

B

SE

0.21 0.23

0.03 0.03

0.05 0.06

0.14* 0.04

0.03 0.03

−0.02 0.06

0.06 0.05

−0.02

0.01

−0.01

0.01

0.01

0.01

−0.002

0.002

−0.07

0.06

0.11

0.03

0.06

0.56*

0.12

0.14*

0.08

0.46**

0.33

−0.06

0.03

−0.26

0.06

−0.02

0.03

−0.22

0.06

−0.17*

0.05

−0.32**

0.19

−0.02

0.03

−0.16*

0.06

−0.04

0.03

−0.08

0.06

0.08*

0.05

0.57*

0.20

0.03 −0.03*

0.04 0.01

0.02 −0.01

0.07 0.02

0.03 −0.01

0.04 0.08

−0.06 0.01

0.07 0.02

0.07 0.02

0.06 0.01

0.31 −0.25*

0.23 0.05

0.19* 0.49*

0.02 0.01

0.23*

0.06

−0.08* 0.44*

0.03 0.02

0.23

0.08

0.11* 0.14*

0.03 0.02

0.49*

0.11

*

−0.04

0.03

0.01

0.06

0.06

0.34

0.25

0.25*

B

Amounta paid

Selection model

−0.04* 0.09

−0.01

B

Amounta paid

Selection model

B

SE 0.14 0.14*

−0.01*

−0.01

B

SE

0.04 0.04

0.02 0.33

0.15 0.18

0.001

−0.03*

0.01

0.04

0.18

0.06

0.54*

0.05

0.66

0.12

0.53*

0.06

0.68*

0.14

0.82*

0.18

3.30*

0.84

0.27*

0.07

0.08

0.09

0.26*

0.06

0.03

0.09

0.09

0.10

0.93*

0.04

0.56*

0.04

−0.01

0.07

0.49*

0.03

0.27

0.09

0.05

0.06

−0.34

0.21

0.32*

0.05

0.13*

0.07

0.22*

0.04

0.05

0.07

0.04

0.08

0.19

0.28

0.36*

0.06

0.18*

0.08

0.39*

0.05

−0.04

0.09

0.12

0.09

0.56

0.39

0.29

*

0.34

0.18

−0.07

0.29

0.23

0.28

−0.73

0.90

−0.25

0.25

0.02.

0.32*

0.05

0.14*

0.08

0.37*

0.04

0.25*

0.09

0.07

0.08

0.19

0.33

0.07

0.05

0.05

0.07

0.06

0.04

0.05

0.07

0.02

0.08

0.41

0.34

0.00

0.06

−0.01

0.08

0.06

0.05

0.09

0.08

0.07

0.09

0.21

0.39

0.07

0.05

0.06

0.08

0.04

0.05

0.04

0.08

0.04

0.08

0.21

0.31

−0.05

0.04

0.06*

0.07

0.15*

0.04

0.05

0.07

0.12

0.08

0.38

0.36

0.02

0.06

0.11

0.09

−0.04

0.05

−0.23*

0.09

−0.16

0.11

−0.64

0.05

*

0.08

0.14

0.11

−0.03

0.06

−0.02

0.11

−0.02

0.12

0.35

0.45

−3.16* 3690 −0.07 0.39

0.15

9.04*

0.03

−3.7* 2845 −0.01 0.10

0.14

7.31

0.89

−3.6 504 1.7* 18.27*

0.36

6.07*

2.1

−0.27

130.24*

129.08

90.23

J. Arsenijevic et al. / Health Policy 119 (2015) 1366–1374

1373

Table 4 Results of the three linear regressions (payers). Explanatory variables

Dependent variables (LN transformation) Official copayments Coefficient

SE

Payments for “bought and brought goods”

Informal patient payments

Coefficient

Coefficient

SE

−0.11 −0.09 −0.006

SE

Gender Marital status Age

2 = female/1 = male 1 = married/0 = not married age in years

0.04 0.06 −0.01*

0.05 0.05 0.02

0.02 0.08 −0.007*

0.05 0.05 0.002

Education level University degree Up to high school

1 = yes/0 = no 1 = yes/0 = no

0.22 −0.22*

0.11 0.06

0.60* −0.22*

0.12 0.06

0.52** 0.05

0.28 0.02

0.18 0. 04 −0.01 0.16 0.27* 0.22* 0.67* 0.08 0.01 0.14* 0.018* −0.26 0.15* 0.06 0.02 0.06 0.07 0.10 0.13 5.5 3960 0.06

0.30 0.08 0.02 0.05 0.03 0.07 0.11 0.09 0.05 0.07 0.08 0.29 0.07 0.07 0.08 0.08 0.08 0.09 0.11 0.49

0.15 0.07 0.02 0.05 0.03 0.07 0.11 0.08 0.05 0.07 0.07 0.27 0.07 0.07 0.08 0.08 0.07 0.09 0.10

−0.65 0.18 −0.26 −0.03 0.17* 0.14 1.27 0.73** −0.29 0.26 0.22 0.07 −0.46 0.19 0.04 0.26 −0.32 −0.31 0.32 6.33* 504 0.14

0.78 0.23 0.05 0.06 0.09 0.26 0.81 0.35 0.21 0.21 0.32 0.97 0.27 0.29 0.33 0.31 0.29 0.42 0.45 2.03

Work status Nationality Household size Urban Perceived health Exempted groups Consumption per person Asthma and bronhospasm Cardiovascular disease Abdomen disease Diabetes Epilepsy Progressive disease Rheumatology disease Legs or feet disease Beck and neck disease Ophthalmology disease Mental illness Hearing-speech difficulties Const N R2 * **

1 = working/0 = not working 1 = Serbian/0 = other number of household members 1 = city/0 = rural from 1 = very good to 4 = very bad 1 = exempted/0 = not-exempted 1 = more than absolute poverty line 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed 1 = diagnosed/0 = not diagnosed

0.64* −0.06 0.01 0.06 0.23* 0.10 0.65** 0.02 −0.03 0.06 0.12 −0.02 0.25 0.08 0.12 −0.04 0.05 −0.22 −0.02 5.32* 2845 0.07

0.15 0.17 0.007

p ≤ 0.05. p ≤ 0.10.

for additional funding [3] Thus, the distinction between the two types of unofficial payments in empirical research is important. Future research should use longitudinal data to analyse the evolution and dynamics of these payments at different time points. Furthermore, using qualitative data can give better insight in the determinants of these payments. In some countries, health care users are more willing to pay informally for public health care services than officially in private facilities [3]. It would be useful to examine willingness to buy and bring foods in public services instead of paying for them in private facilities. Acknowledgements The study is financed by the European Commission under the 7th Framework Programme, Theme 8 Socioeconomic Sciences and Humanities, Project ASSPRO CEE 2007 (Grant Agreement no. 217431). The views expressed in this publication are the sole responsibility of the authors and do not necessarily reflect the views of the European Commission or its services. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.healthpol.2015.07.005.

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