1. Informal gifts in public health care: Scarce resources or governance failure? Evidence from Albania using Living Standard Measurement Survey Sonila TOMINI; Truman G. PACKARD World Bank International Conference Poverty and Social Inclusion in the Western Balkans Brussels, Belgium, December 14-15, 2010

2. Maastricht Graduate School of Governance Outline Introduction The aim of the Paper The Model Results

3. Maastricht Graduate School of Governance Definition of Informal Payments Informal payments are payments to individual and institutional providers in-kind or cash that are outside the official payment channels, or are purchases that are meant to be covered by the health-care system. (Lewis 1999) Informal payments in health care can be conceptualised as strategies to cope with lack of resources and poor performance at both the demand and supply side: –Patients pay informally to jump the queue, receive higher quality of services or more care; –Providers of medical care can also use these payments as an instrument to cope with their low salaries.

4. Maastricht Graduate School of Governance Evidence of IP in CEE & FSU Countries

5. Maastricht Graduate School of Governance The aim of the Paper The main aim of this paper is to test for the main motives behind informal payments in health care and to assess the effectiveness of various measures seeking to reduce such informal payments over the last years in Albania.

6. Maastricht Graduate School of Governance Causes of informal payments & observed effects

7. Maastricht Graduate School of Governance Evidence of IP in Albania The share of patients paying & the amount paid as informal gifts

8. Maastricht Graduate School of Governance Data & The Model ALSMS 2002-2005-2008 Tobit & Two stage Heckman –Selectivity issue Propensity score matching

9. Maastricht Graduate School of Governance Heckman selection model

10. Maastricht Graduate School of Governance Propensity Score Matching - Time impact on individual characteristics for paying informal gifts

11. Maastricht Graduate School of Governance Individual Perceptions Which one of the following do you agree with in terms of unofficial private out-of-pocket fees paid at health facilities in Albania?

12. Maastricht Graduate School of Governance Conclusion & Discussion Informal gifts to medical staff are widespread in Albania both in outpatient and inpatient services. The evidences coming from ALSMS 2002-2008 suggest that even though scarcity of resources seems to be associated with such phenomenon, governance failures in health care are the main reason behind them. –The past reforms and reorganisation of the health sector has only managed to achieve small reductions in the amounts and incidence of such payments. The data analysis in this paper demonstrates that the people suffering the effects of informal gifts are the poorest or regionally disadvantaged (i.e. inhabitants of rural areas or impoverished regions).