The hospitals have enough potential to improve various aspects of their responsiveness. We suggest a number of measures can help improve the non-clinical aspects of care. These include: using educational courses to improve the knowledge and attitudes of medical and nonmedical staff, changing the resource allocation method, and using quality tools such as reengineering to modify the healthcare delivery processes.

Background: Nowadays, a growing literature reveals how patients use informal payments to seek either better treatment or additional services, but little systematic review has been accomplished for synthesizing the main factors. The purpose of this study was to analyze the content of literatures to demonstrate the factors for informal patient payments. Methods: In this systematic review study, PubMed, Web of Science, Wiley Online Library, Science Direct, Ovid, Scopus, and Iranian databases were investigated without time limitation for eligible English and Persian studies. Achieved data were analyzed using content analysis approach and MAXQDA 10 software. Results: Themes related to informal payments in external context of health system were demographic features of health service consumers, patient's personality features and social & cultural backgrounds of the community. Health system challenges' themes were about stewardship weakness, and sustainable financing and social protection weakness. These were followed by human resources' organizational behavior challenges, drugs, medical products, and services delivery provision process challenges and finally change management weakness for reducing and dealing with IPs. Conclusion: It appears that improving the quality of health care services and accurate monitoring of delivery processes, along with performing some strategies for regulating payroll and medical tariffs, strict rules and regulations and improving health staff motivation, would be effective ways against informal payments. Improving the health insurance contribution, promoting transparency & accountability in health system especially in financing, identify precise control mechanism, using empower patient/public related approach, modifying community perception, reinforcing social resistance to unofficial payments and rebuilt lost social capital in health care are some of the other recommendations in this field. To practice these strategies, a comprehensive and systemic vision and approach is needed, however, the key point is that before applying any strategy the impact of this strategy on access, efficiency, equity, and other health systems' goals and policies should be investigated due to the consideration.

It appears that "implementing regulation" and "financial problems" embrace over 50% of the barriers. Apparently, the new approach to hospitals' autonomy has not achieved the desired goals. Considering the contextual factor, the evidence and identification of the clear role of various stakeholders should be essential determinants. Partial implementation of this policy without paying attention to the other aspects would end in failure. The results showed insufficient budget to be the most influential factor that posed a dilemma in implementing the BOTs' policy. However, BOTs in Iranian health system need to strive toward a higher level of performance that will improve effectiveness and efficiency now more than ever.

BackgroundPatient’s Informal payments is among the main source of health care financing in some countries. This paper aimed at determining the patient informal payments and relative factors in Cardiac Surgery Departments (CSD) in hospitals affiliated to Mashhad University of Medical Sciences (MUMS) in 2013.MethodsIn this cross-sectional study, 316 discharged patients were selected using multi-stage sampling. Data gathering tool was a questionnaire which was filled by structured telephone interviews. We used quantitative content analysis for open-ended questions besides descriptive statistics and nonparametric tests by SPSS 16 at 0.05 Sig level.ResultsSixteen (5.93%) patients made voluntary informal payments. The purpose of payment was: “gratitude” (43.75%), satisfaction with health services provided” (31.25%) and (18.75%) for better quality of services. About 75% of the payments were occurred during receiving health care services. The main causes were “no request for informal payments” (98.14%), “not affording to pay for informal payments” (73.33%) and “paying the hospital expenses by taking out a loan” (55.91%). Responders said they would pay informally in demand situation (51.85%) just for patient’s health priority, 40.71% would also “search for other alternative solutions” and 27.33% “accepted the demand as a kind of gratitude culture”. Twenty four patients (8.9%) had experienced mandatory informal payments during the last 6 months. The minimum amount of payment was 62.5$ and the maximum was 3125$. There was a significant relationship between the way of referring to medical centers and informal patient's payment (P ≤0.05).ConclusionDespite the widespread prevalent belief about informal payments in public hospitals —particularly to the well-known physicians — such judgment cannot be generalized. The main reasons for the low informal payments in the current study were the personality characteristics of the physicians and hospital staff, their moral conscience and commitment to professional ethics, cultural factors and social-economic status of the patients. Health care system should notify people about their rights specially the payments calculation mechanism and methods. Better communication with the public and especially the media can help to correct attitude toward these payments.

There was a gap between the ideal situation and the current situation of family physician quality of services. Our suggestion is maintaining a strong focus on patients, creating a medical practice that would exceed patients' expectations, providing high-quality healthcare services, and realizing the continuous improvement of all processes. In both tangible and responsive, the gap was greater than the other dimensions. It is recommended that more attention should be paid to the physical appearance of the health center environment and the availability of staff and employees.