Unofficial fees in Bangladesh: price, equity and institutional issues

The widespread collection of unofficial fees at health facilities is a comm on form of rent-seeking behaviour in Bangladesh. Typically, unofficial fees come in the form of cash payments for the performance of required services , for direct purchase of drugs and medical-surgical requisites, and for ser vice access. Using observational and interview methods, this study explores linkages between official and unofficial fees at three Bangladesh health f acility levels: primary care Thana Health Complexes, secondary or district hospitals, and medical college hospitals. The study estimates payment level s for different income classes and different payor types at these facilitie s, thereby highlighting potential equity, price and institutional questions associated with unofficial fees. Not only does the practice have clear inc ome and equity effects, there also appear to be direct effects upon patient satisfaction, perception of quality, and the ability to pay for health ser vices. The article concludes with a discussion of 'rent capture' processes at Bangladesh facilities and the effect of unofficial fees in six areas of health sector reform: displaced official policies, reduced merit goods prod uction, upward income redistribution, distorted human resource development, growth of facility inefficiency, and obstruction of market reforms.