Informal payments for health services: the experience of Bulgaria after 10 years of formal co-payments.

BACKGROUND: Informal payments were reported in Bulgaria before and after the introduction of formal co-payments for services included in the basic benefits package in 2000. The aim of our study was to establish the current scale and type of informal payments, as well as public attitudes towards these payments. METHODS: A nationally representative survey of 1003 individuals was conducted in Bulgaria in July 2010 using face-to-face interviews based on a standardized questionnaire. Respondents were selected through a multi-stage random probability method. The questionnaire included questions on total informal payments (in cash and in kind) for health services used by the respondent during the preceding 12 months. RESULTS: About 13% of users reported informal payments for outpatient visits and 33% of users reported to have paid informally for hospitalizations. The average amount paid informally for inpatient services was nearly twice higher than that for outpatient services. More than 50% of the sample had negative attitudes towards informal payments in both cash and kind, but about 27% of respondents had a positive attitude towards giving gifts in kind. Regression analysis showed that respondents with higher levels of education had more negative attitudes towards informal cash payments. Positive attitudes towards gifts in kind were more often stated by citizens of larger cities. CONCLUSION: Informal payments continue to exist in Bulgaria irrespective of the formal co-payments introduced in 2000. Although the problem has been recognized in Bulgaria, policies should aim to eliminate the underlying structural reasons for such payments.

Out-of-pocket payments for health care services in Bulgaria: financial burden and barrier to access.

BACKGROUND: In recent years, Bulgaria has increasingly relied on out-of-pocket payments as one of the main sources of health care financing. However, it is largely unknown whether the official patient charges, combined with informal payments, are affordable for the population. Our study aimed to explore the scale of out-of-pocket payments for health care services and their affordability. METHODS: Data were collected in two nationally representative surveys, conducted in Bulgaria in 2010 and 2011, using face-to-face interviews based on a standardized questionnaire. To select respondents, a multi-stage random probability method was used. The questionnaire included questions on the out-of-pocket payments for health care services used by the respondent during the preceding 12 months. RESULTS: In total, 75.7% (2010) and 84.0% (2011) of outpatient service users reported to have paid out-of-pocket, with 12.6% (2010) and 9.7% (2011) of users reporting informal payments. Of those who had used inpatient services, 66.5% (2010) and 63.1% (2011) reported to have made out-of-pocket payments, with 31.8% (2010) and 18.3% (2011) reporting to have paid informally. We found large inability to pay indicated by the need to borrow money and/or forego services. Regression analysis showed that the inability to pay is especially pronounced among those with poor health status and chronic diseases and those on low household incomes. CONCLUSION: The high level of both formal and informal out-of-pocket payments for health care services in Bulgaria poses a considerable burden for households and undermines access to health services for poorer parts of the population.

Bulgaria health system review.

In the last 20 years, demographic development in Bulgaria has been characterized by population decline, a low crude birth rate, a low fertility rate, a high mortality rate and an ageing population. A stabilizing political situation since the early 2000s and an economic upsurge since the mid-2000s were important factors in the slight increase of the birth and fertility rates and the slight decrease in standardized death rates. In general, Bulgaria lags behind European Union (EU) averages in most mortality and morbidity indicators. Life expectancy at birth reached 73.3 years in 2008 with the main three causes of death being diseases of the circulatory system, malignant neoplasms and diseases of the respiratory system. One of the most important risk factors overall is smoking, and the average standardized death rate for smoking-related causes in 2008 was twice as high as the EU15 average. The Bulgarian health system is characterized by limited statism. The Ministry of Health is responsible for national health policy and the overall organization and functioning of the health system and coordinates with all ministries with relevance to public health. The key players in the insurance system are the insured individuals, the health care providers and the third party payers, comprising the National Health Insurance Fund, the single payer in the social health insurance (SHI) system, and voluntary health insurance companies (VHICs). Health financing consists of a publicprivate mix. Health care is financed from compulsory health insurance contributions, taxes, outofpocket (OOP) payments, voluntary health insurance (VHI) premiums, corporate payments, donations, and external funding. Total health expenditure (THE) as a share of gross domestic product (GDP) increased from 5.3% in 1995 to 7.3% in 2008. At the latter date it consisted of 36.5% OOP payments, 34.8% SHI, 13.6% Ministry of Health expenditure, 9.4% municipality expenditure and 0.3% VHI. Informal payments in the health sector represent a substantial part of total OOP payments (47.1% in 2006). The health system is economically unstable and health care establishments, most notably hospitals, are suffering from underfunding. Planning of outpatient health care is based on a territorial principle. Investment for state and municipal health establishments is financed from the state or municipal share in the establishments capital. In the first quarter of 2009, health workers accounted for 4.9% of the total workforce. Compared to other countries, the relative number of physicians and dentists is particularly high but the relative number of nurses remains well below the EU15, EU12 and EU27 averages. Bulgaria is faced with increased professional mobility, which is becoming particularly challenging. There is an oversupply of acute care beds and an undersupply of longterm care and rehabilitation services. Health care reforms after 1989 focused predominantly on ambulatory care and the restructuring of the hospital sector is still pending on the government agenda. Citizens as well as medical professionals are dissatisfied with the health care system and equity is a challenge not only because of differences in health needs, but also because of socioeconomic disparities and territorial imbalances. The need for further reform is pronounced, particularly in view of the low health status of the population. Structural reforms and increased competitiveness in the system as well as an overall support of reform concepts and measures are prerequisites for successful progress.

What have 10 years of health insurance reforms brought about in Bulgaria? Re-appraising the Health Insurance Act of 1998.

This article discusses the financial reforms in the Bulgarian public health care sector. Since 1998, when the Bulgarian parliament passed the Health Insurance Act, compulsory contributions for social health insurance have become the main source of health care financing. They replaced the previous tax-based health care funding mechanism. This article reviews empirical evidence and macro indicators to analyse to what extent the expectations of this reform are achieved. Two groups of sources are reviewed: (1) publications prior to the implementation of the social health insurance in Bulgaria that discuss its potential impact; (2) publications after the insurance implementation, that investigate the actual impact of this reform. The results suggest that social health insurance in Bulgaria brought about certain efficiency improvements in the public health care sector. However, the overall social benefit of the reform is doubtful. The main reasons for this are related to the ineffective organisation of the Bulgarian public health care sector, as well as to the overall lack of financial resources for health care in the country.