Across low- and middle-income countries (LMICs), over 50% of total health care spending is derived from out-of-pocket expenses. Some of these are formal recognised tariffs in public health systems. However, a proportion are irregular or informal payments (bribes/kick-backs). It is hypothesised that these informal payments are used to subsidise the poor at the expense of the rich after the fashion of Robin Hood in English folklore. Enter results from a series of publically available repeated surveys called ‘Afrobarometer‘. Here public attitudes and experiences relating to democracy and governance are surveyed in 18 African counties. Nationally representative samples of over 25,000 individuals are selected randomly across participating countries. Afrobarometer provides the data for an important study  of the extent to which informal payments were elicited across people of different income levels (according to the Lived Poverty Index). Far from confirming the Robin Hood hypothesis, the authors find a higher occurrence of bribe paying among the poorest people across the countries studied – elasticity is negative in that the richer the person, the lower the probability that they will have paid a bribe on attending a health care facility. These results are similar to those obtained in a previous study in Hungary. There is some evidence that the problem is worse in cities where service providers are less likely to have known or have community affiliations with patients. This finding reminds me of the Bible scripture – “For whosoever hath, to him shall be given… but whosoever hath not, from him shall be taken away...” (Matthew 13:12).
— Richard Lilford, CLAHRC WM Director
- Kankeu HT, Ventelou B. Socioeconomic inequalities in informal payments for health care: An assessment of the ‘Robin Hood’ hypothesis in 33 African countries. Soc Sci Med. 2016; 151: 173-86.