Informal payments for primary health services in Zambia: Evidence from a health facility patient exit survey.

Although informal patient payments are a common feature of health systems in developing countries, little empirical evidence is available about the prevalence and magnitude of these payments in African health systems. The main objective of this study was to estimate the prevalence and determinants of informal patient payments in the Zambian health system. The study is based on a patient exit survey of 1900 patients that was conducted at government primary health facilities in three provinces in Zambia in 2018. We employ a two-part regression model to estimate first the determinants of the likelihood of incurring informal payments and the determinants of the amount paid. The results show that 6.2% of patients who visited government primary health facilities reported incurring informal payments. The average amount paid (ranging from US$ 1.41 to 3.36) can amount to a significant cost burden to some patients given the context of high levels of poverty in Zambia. Findings suggest that the prevalence of informal payments is significantly associated with scarcity of healthcare resources at health facilities. Facilities appear to informally impose charges in response to inadequate staffing and general resource shortages in health facilities. Further, informal payments are more common in urban facilities. From a policy perspective, increasing general facility budgets and staffing would be required to reduce incentives for informal payments in the Zambian health system. Our study also raises a policy concern that informal payments can undermine public confidence in the government policy of free primary healthcare. The study suggests further research into the phenomenon of informal payments in healthcare in Africa.