Table 4.

Informal patient payment factors related to internal context of health system

Theme	Category	Code
Stewardship weakness	lack of legal support towards IPs • Structural problems & inefficiencies of the health services providing network • Weak management • Lack of transparency & accountability • Lack of partnership and cooperation with other parts & stakeholders • Inefficiency in health information system	lack of regulation sanction and penalties for illegal behavior- Lack of regulation- lack of referral system-poor system design and structural weakness in providing services –duplication and fragmentation in health system- lack of control- limited management capacity- weak management in health system, hospital and medical center- related factors of resource allocation - less health insurance contribution- lack of private sector involvement- lack of support of health workers and professional association and their commitment or involvement-Lack of information- lack of data sources- lack of information on performance- lack of a comprehensive financial and tax reporting system-
Sustainable financing and social protection weakness	• Inefficient use of resources due to unfocused approach of funding activities and interventions for financing purposes • Lack of transparency in the health financing system • Insufficiency and inefficiency of the insurance system • Poor and vague definition of the basic benefit package	funding shortage in health system- inefficiency in financial management of health system- reliance on out-of-pocket payments- inefficiencies of payment mechanisms to providers- unrealistic, insufficient inequitable tariffs- Low income of doctors & medical personnel & deferred claims- inefficiency in financing health care system- insurance deduction & delayed reimbursement- Insurance coverage problems- Inadequate social protection for poor and other vulnerable groups
Human resources’ organizational behavior challenges	• Health workforces’ perception and motivation • Poor human resource management • Social position or authority • Moral/ ethical related issues	insufficient official income of health personnel and physicians-- lack of staff motivation- for higher standard of living in providers - lack of government attention to providers motivation- Imbalance in the distribution of medical staff - lack of control and monitoring on medical staff- misuse of monopoly power and market position- physician competency -IPs for well-known physicians- Lack of training in ethics- Low moral standards of the medical profession- low moral and ethical reasons-
Challenges of drugs, medical products and services delivery provision process	• The complexity & nature of the services • Organizational feature of the health services provider • inefficient patient complain process • Quality of health care services • Access to health care services • irrational prescription • Lack of medicine & other medical supplies	health workers providers specialty- length of stay- type of health services- kind of health services facilities- additional services- receiving special attention- better service quality- better care- skip waiting time- access to care -quick access to services- lack of access to health care services- scarcity of medicines and other supplies- irrational drug and treatment prescription- irrational diagnosis test prescription-
Change management weakness	• Lack of political will • Lack of follow up reform • Reform failure	lack of the reform monitoring- lack of range of policy tools in system for eliminating IPs-