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Background: A growing number of studies suggest that informal (illicit) fees for healthcare are prevalent in low and middle income countries. These fees are regressive and deeply embedded, often proving impervious to policy interventions. Methods: The author conducted a critical interpretive synthesis of peer reviewed literature, grey literature, global standards, and donor funding related to informal fees in order to assess their prevalence, critically interrogate the paradigms that are applied to understanding them, assess to what extent fees are addressed in global policy and funding, and propose future areas for policy and research. In contrast to a systematic review, critical interpretive synthesis fosters crossdisciplinary research that encompasses quantitative, qualitative, and conceptual work. As such, it can open new avenues of discussion on persistent public health problems whose roots reach into the political, social, and cultural realms. Pursuant to established methods for critical interpretive synthesis, key terms were searched in databases and selected journals. Resources were added through an iterative process of developing new lines of enquiry from the initial papers identified, and obtaining resources identified in paper citations. Findings: Patients and providers perceive informal fees on a continuum from gift giving to forced payment. The often disrespectful and coercive nature of fee requests undermines trust and future utilization, and perpetuates helplessness and disempowerment. Health system “hardware” drivers, such as low salaries, scarcity of health workers, and poor infrastructure are widely explored in the literature. “Software” drivers, such as values and norms, are less explored, except in a few qualitative investigations. Policy literature is dominated by rational choice approaches. While the prevalence of fees is well documented, maternal health strategies and donor policies acknowledge the relevance of all out of pocket fees (both formal and informal) with little e if any e attention to informal fees as such. Interpretation: The empirical literature about informal fees is limited by the paradigms applied. Rational choice approaches ignore cultural and practical meanings. International standards and strategies reflect this limitation, presumably exacerbated by reluctance to describe illicit practices. Two trends in international health and development offer opportunities. First, the emerging quality agenda in global health could include informal fees. Second, the governance field is evolving to focus on addressing the function of informal practice, rather than resorting solely to regulation and incentives to end it. Critical interpretive synthesis insights on the function of informal feese from expression of consumer power to resistance of the health system e illuminates possible interventions beyond simple prohibition or incentives. This study is notable for its examination of both public health literature and policy. However, all data regarding informal fees were secondary, the key limitation of this study. Funding: Funding for this research was provided by the MacArthur Foundation. Abstract #: 01GMHE010

Collection and use of human biological specimens in research: Is there adequate ethics governance in Africa?