Informal payments in health facilities in Peru in 2018: Analysis of a cross-sectional survey

Background: The Latin American region demonstrates the lowest levels of trust in health systems globally. Institutional corruption is a major factor in eroding trust. Corruption in health services, including extracting bribes and informal payments from patients, directly harms health outcomes and weakens services intended as public goods. In this study, we aim to characterize the frequency and distribution of informal payments within public health services in Peru. Methods: We conducted a secondary analysis of a nationally representative cross-sectional survey, the 2018 National Household Survey of Living Conditions and Poverty, and identified all individuals reporting health insurance from the Ministry of Health (SIS-MINSA) or Social Security (ESSALUD). We defined self-reported informal payments in 2 ways: 1) being asked to pay a bribe at a health establishment in the past year (direct method), and 2) creating an overall indicator for non-zero cost of care for services that should be free (indirect method). We used descriptive statistics to quantify informal payments and bivariate analysis to identify sociodemographic characteristics of those most frequently reporting such payments. Findings: 132,355 people were surveyed, including 69,839 (52.8%) with coverage from SIS-MINSA and 30,461 (23.03%) from ESSALUD. Less than 1% of participants directly reported informal payments, either at SIS-MINSA services (0.22%); or at ESSALUD (0.42%). Indirect reporting was more prevalent, including up to 10% of surgery patients and 17% of those hospitalized in SIS-MINSA facilities. Wealthier patients (19%) were more likely to report such payments. Interpretation: While direct reporting of bribery was uncommon, we found moderate prevalence of informal payments in public health services in Peru using an indirect assessment method. Indirect reporting may exceed direct reporting due to difficulty in distinguishing appropriate and inappropriate payments, fear of reporting health care workers’ behavior, or social tolerance of informal payments. Informal payments were more common among those with greater financial capital, indicating they may obtain enhanced services. Further research on patients’ perception and reporting of informal payments is a key step towards accurate measurement and evidence-based intervention.