Table 1 Causes of informal payments and observed effects

1. Cultural

1. Culture of gratitude gifts and tipping

1. Money and in kind gifts paid to medical staff (usually after the services received).

2. Patients declare gifts to medical staff mostly as voluntary.

3. A relatively moderate incidence of such payments, usually of modest value.

2. Economic

1. Demand side factors

-free heath care access

2. Supply side factors

-Inadequate funding

-Low salaries of health care staff.

-Investments oriented more towards access rather than quality of services.

1. Unequal amounts paid for inpatient and outpatient health services.

2. Informal payments resemble a 'fee-for-service' model (as patients may use informal payments as top ups or for getting better quality of service).

3. High income patients will pay higher informal payment.

4. Having health insurance will lower the probability of paying informally.

3. Governance

1. Lack of control and accountability leading to unethical behaviour of medical staff.

2. Weak rule of law and corruption control.

1. High incidence of explicitly requested payments.

2. Probability of paying informally is dependent on the knowledge and bargaining power of the patients.

3. Low numbers of prosecuted cases of corrupted medical staff.