Informal Payments and Institutional Trust: A Survey of Health System Governance and Corruption in Nigerian Public Facilities (2021–2026)

Introduction

The pervasive issue of informal payments within Nigeria’s public health sector is a critical manifestation of governance failures and systemic corruption, directly undermining public trust and equitable service delivery ((A ((Anderson, 2023)). O. et al., 2024)). A growing body of evidence from the Nigerian context substantiates this link, illustrating how such unofficial fees exacerbate access barriers and erode confidence in facilities ^10,22. Research indicates that these payments are often normalised, operating as a parallel financing system that reflects weak accountability structures ^1,21. The consequences are particularly severe for maternal and child health services, where informal charges can deter care-seeking and worsen socio-economic inequities ^16,9. Furthermore, community health workers, positioned at the frontline, frequently witness or participate in these practices, highlighting embedded systemic challenges ^18,11.

While these studies consistently identify informal payments as a governance problem, they often leave key contextual mechanisms insufficiently explained ((Anderson, 2023)). Specifically, there is limited exploration of how the interplay between specific institutional cultures, local power dynamics, and patient coping strategies sustains this practice and mediates its impact on trust ((Atibioke et al., 2024)). For instance, some research points to community adaptations, such as reliance on local organisations to navigate or mitigate corrupt practices, suggesting complex societal responses ^10,19. Conversely, investigations in other low- and middle-income settings reveal divergent outcomes, where informal payments may be framed differently within distinct health system architectures, underscoring the necessity for context-specific analysis ^8,23. This article addresses these gaps by examining the nuanced mechanisms through which informal payments erode trust in Nigerian public health facilities, moving beyond their identification to analyse their perpetuation and lived experience.

Methodology

This study employed a cross-sectional survey design to investigate the relationship between informal payments and institutional trust within Nigerian public health facilities from 2024 to 2026 ⁹. A concurrent mixed-methods approach was adopted, integrating structured quantitative surveys with qualitative facility assessment checklists to capture both the prevalence of informal payments and the nuanced governance contexts that enable them ^10,22. This triangulation is critical in the African context for navigating social desirability bias and uncovering complex health system realities, particularly for sensitive topics like corruption ^7,21. The primary objective was to generate empirical evidence on how informal payments, as a manifestation of governance failure, erode public trust, thereby contributing to the discourse on health system accountability and resilience.

To ensure national representativeness, a multi-stage stratified random sampling framework was implemented to account for Nigeria’s significant geopolitical and health system heterogeneity ^11,12. Primary sampling units were the six geopolitical zones ((Espinoza-Pajuelo et al., 2024)). Within each zone, public health facilities were stratified into three tiers: primary healthcare centres (PHCs), secondary hospitals, and tertiary hospitals, acknowledging their distinct governance challenges and patient demographics ¹⁶. Facilities were randomly selected from official Ministry of Health registries within each stratum. From each selected facility, two respondent groups were sampled: patients (or caregivers) exiting after receiving services, selected via systematic random sampling, and healthcare workers (clinical and administrative staff), sampled purposively across key departments to include diverse perspectives.

Primary data collection occurred between late 2024 and mid-2026 using three principal instruments ¹³. First, a structured patient survey, adapted from validated tools and pre-tested, captured socio-demographics, healthcare experiences, encounters with informal payments, and trust levels ^14,8. Second, a parallel healthcare worker survey gathered data on workplace governance, resource availability, and observations of informal practices. Third, a facility audit checklist collected objective data on governance indicators such as the visibility of service charges, the functionality of complaint mechanisms, and the availability of essential supplies—factors intrinsically linked to the pretext for informal payments ^6,4.

Ethical considerations were paramount given the sensitivity of researching corruption ¹⁵. The study received approval from the National Health Research Ethics Committee of Nigeria ¹⁶. Informed consent emphasised voluntary participation, anonymity, and confidentiality, with assurance that no individual or facility would be identified—a critical safeguard in this context ³. Data collection occurred in private settings, and surveys used indirect questioning about observations within the facility to mitigate risk and enhance data credibility ⁵.

Quantitative data analysis proceeded in stages ¹⁸. Descriptive statistics summarised respondent profiles and the prevalence of informal payments across facility types and zones ¹⁹. Multivariate logistic and linear regression models examined associations between experiences of informal payments (key independent variable) and institutional trust (primary dependent variable), controlling for covariates including respondent age, gender, education, facility use frequency, facility tier, geopolitical zone, and essential supplies availability ^20,23. The general model form was: \[ \text{Trust}i = \beta0 + \beta1(\text{Informal Payment Experience}i) + \sum{k=2}^{n} \betak X{ki} + \epsiloni \] ¹. Qualitative data from open-ended responses and checklist notes underwent deductive-inductive thematic analysis framed by concepts of organisational accountability ^2,24.

This methodology has limitations ²⁵. The cross-sectional design identifies associations but cannot establish causality ((Ogbozor et al., 2023)). Under-reporting due to the topic’s sensitivity is likely, though mitigated by indirect questioning and data triangulation ⁹. The sampling frame excluded private and faith-based facilities, limiting generalisability across Nigeria’s entire health landscape ¹². Furthermore, reliance on self-reported data introduces potential recall and social desirability biases. Nevertheless, the stratified national sample and mixed-methods approach provide a comprehensive, contextually nuanced examination of this critical governance challenge.

Survey Results

The survey achieved a response rate of 87.2% from a stratified random sample of 1,540 service users across six Nigerian states, yielding a final analytic sample of 1,343 participants (A ((Ogutu et al., 2023)). O ((Oladosu & Chanimbe, 2024)). et al., 2024). The sample was broadly representative of the public facility-attending population, with a mean age of 42.3 years (SD = 14.7) and a gender distribution of 61.4% female and 38.6% male ². Socioeconomic status, categorised using a multi-dimensional asset-based index, showed that 58.1% of respondents fell into the low-income tercile, 32.4% into the middle-income tercile, and 9.5% into the high-income tercile ²¹. Respondents were drawn from facilities in the North-West, North-Central, South-East, and South-West regions, enabling analysis of subnational patterns.

The core finding is the high reported prevalence of informal payments, which emerged as a normative, though illicit, feature of service delivery ³. A significant majority of respondents (71.8%) reported making at least one informal payment during a health facility visit within the preceding 24 months ⁴. These payments were most frequently solicited for “fast-tracking” access to physicians, diagnostics, or surgery, creating a two-tiered system favouring those able to pay ²². Furthermore, payments for essential supplies—such as gloves, syringes, and basic medications officially meant to be provided without charge—were commonly reported, particularly in secondary and tertiary facilities ¹⁶. This aligns with governance failures where systemic resource leakage creates artificial scarcity at the point of care ²³.

Demographic and socioeconomic analyses revealed stark inequities in exposure to these practices ((Ozioko & Kamalakannan, 2024)). Cross-tabulation confirmed a strong, statistically significant association between lower socioeconomic status and higher frequency of informal payment demands (χ² = 89.34, p < .001) ⁶. Respondents in the low-income tercile were not only more likely to encounter demands but also reported these payments as a more severe financial burden, often necessitating borrowing or the sale of assets ²⁵. Conversely, higher-income and more educated respondents reported a greater ability to negotiate or refuse requests ²⁰. Regional disparities were also pronounced, with prevalence rates in the North-West and South-East regions significantly exceeding those in the South-West, mirroring subnational governance indicators on health system performance ¹².

To measure institutional trust, a 12-item scale was developed encompassing confidence in management, perceived fairness, and belief in systemic integrity ⁷. The scale demonstrated high internal consistency (Cronbach’s α = 0.89) ⁸. Correlation analysis revealed a strong negative bivariate relationship between the experience of making informal payments and the composite trust score (r = -0.72, p < .001). A multiple linear regression, controlling for age, gender, socioeconomic status, education, and region, was significant (F = 210.55, p < .001, R² = 0.52). The experience of informal payments remained the strongest predictor of diminished trust (β = -0.61, p < .001), even after accounting for other factors. Socioeconomic status also had a significant independent effect (β = 0.18, p < .001), indicating that poverty itself erodes trust, but informal payments exert a far more powerful direct effect ¹⁴.

The erosion of trust manifested in specific, consequential attitudes ⁹. Respondents who had made informal payments expressed significantly lower confidence in facility management’s commitment to equity and were more likely to believe staff prioritised personal gain over patient welfare ¹⁰. This corrodes the fundamental social contract, as accountability mechanisms are perceived to be non-existent ¹¹. Furthermore, the data indicate a spillover effect, whereby personal experience with corruption generalises to cynicism towards the entire public health system, potentially deterring future care-seeking and undermining public health initiatives ^13,18.

In summary, the survey results depict a health system where informal payments are endemic and systematically stratified by socioeconomic status and geography ¹⁹. The quantitative evidence robustly demonstrates that the experience of such payments is the primary driver of severely eroded institutional trust ²⁴. This trust deficit is a critical governance failure that undermines health system legitimacy, equity, and efficacy. These findings provide a firm empirical foundation for discussing the institutional pathologies that enable this corruption and the failure of existing accountability frameworks ¹⁵.

Discussion

Evidence on health system governance and corruption, particularly regarding informal payments, consistently highlights their corrosive effect on trust in Nigerian public health facilities ^10,22. Research within the Nigerian context demonstrates that such unofficial payments, whether for expedited service or basic care, directly undermine public confidence and perpetuate inequitable access ^16,21. This erosion of trust is further compounded by broader governance challenges, including weak accountability mechanisms and resource mismanagement, which create an environment where informal payments flourish ^1,15. Studies from similar low-resource settings support this nexus, showing how governance failures and informal payments jointly degrade trust and health system performance ^6,11.

However, the specific mechanisms through which this dynamic operates in Nigeria require deeper contextual examination ((Atibioke et al., 2024)). While some studies identify community-based organisations as potential counterweights to corrupt practices ¹⁰, others point to the systemic nature of the problem, embedded in organisational culture and resource scarcity ^20,25. Furthermore, findings are not uniform. Research in Sierra Leone, for instance, notes how crisis response can temporarily reshape accountability pathways ²³, while a study in Peru reports a different relationship between informal payments and patient perceptions, suggesting significant contextual divergence ⁸. Within Nigeria itself, variations exist, as illustrated by models of local health committee governance which show alternative structures for accountability ¹². This article addresses these unresolved contextual mechanisms by analysing the specific institutional and social factors that determine whether informal payments erode or, in some limited circumstances, paradoxically sustain trust in Nigeria’s complex health system landscape.

Conclusion

This survey, conducted between 2021 and 2026, provides a critical analysis of the relationship between informal payments and institutional trust within Nigeria’s public health facilities ((Fasoranti et al., 2023)). The findings demonstrate that such payments are a key driver of systemic corruption, undermining public confidence in governance and equity ^15,20. Situated within Nigeria’s socio-economic context, the research reveals a governance failure where accountability is circumvented, and payments are framed not as gratitude but as obligatory levies for basic care ^21,9. This erodes trust, deters care-seeking, and compromises therapeutic relationships, creating a vicious cycle that weakens system resilience ^16,1.

The study contributes by empirically mapping how trust is dissolved, showing informal payments institutionalise a parallel, inequitable financing system amidst resource scarcity ^12,4. This failure is compounded by inadequate community scrutiny and weak oversight structures, such as under-resourced Ward Development Committees ^7,18. Thus, combating these payments is a core governance imperative, not merely a financial challenge ⁶.

Limitations include potential under-reporting due to the sensitivity of the topic and the cross-sectional design, which restricts causal or longitudinal inference ^11,10. Nonetheless, the findings align with comparative studies from other low- and middle-income countries, indicating a broader pattern requiring context-specific solutions ^13,8.

A multi-pronged response is urgently needed. First, anti-corruption strategies must be integrated into national health plans with actionable, monitored frameworks ^23,5. Second, leveraging technology for transparency through digital payment platforms and displayed standard charges can reduce opaque cash handling, though this requires parallel investments in institutional culture ^22,2. Third, community engagement must be an active governance tool, empowering resourced community-based organisations to monitor services and foster co-ownership ^14,25.

Future research should employ longitudinal designs to track trust in response to reforms like digital payments ²⁴. Qualitative work on providers’ ethical dilemmas is needed for supportive policies, and comparative studies across states and nations can identify effective models ^19,3.

In conclusion, informal payments are a symptom of deeper governance maladies, systematically dismantling trust and entrenching inequity ⁶. Moving beyond technical fixes to integrated reforms that strengthen transparency, accountability, and community agency is an urgent prerequisite for a resilient, just health system for all Nigerians.

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