The Soviet-style model in central and Eastern Europe that provided free health services was radically reformed throughout the 1990s. By 1997, Bulgaria’s healthcare budget was only 50 per cent of the 1990 level. Are there now inequalities in access to care? Researchers from the London School of Hygiene and Medicine address this question.

Free access to healthcare was preserved in the new Bulgarian Constitution and the earlier health system infrastructure remains. But many people now pay for health services through formal user fees or informal payments to staff. Researchers surveyed 1 550 individuals and interviewed 33 patients and 24 healthcare workers. How do people access care in practice? What informal strategies do they use?

Researchers found that:

• Rates of illness vary with income, with highest rates among the poor.
• After adjustment for illness, healthcare use is relatively equal across income levels, although poorer women tend to consult more.
• Health services are the last resort for many people when they have exhausted other options, such as self-treatment, or when they think their condition is urgent.
• Reasons for not consulting include not seeing the illness as serious, self-treating or being unable to afford treatment. Utilisation has decreased in recent years due to deterioration of the system, low priority given to health, and financial barriers.
• The first point of contact with the health system is usually at the primary care level. The principles of access to primary care and referral channels are relatively well understood by most patients and doctors.
• However, men tend to be referred more quickly than women to secondary (specialist, often hospital-based) care. Wealthier individuals are more likely than the poor to bypass primary level care.
• Despite rapid growth of the private sector, it is not heavily used.

People try various strategies to obtain more advanced care, including use of connections, informal payments and accessing emergency services. Although most users go first to the formal state sector, they often use a connection to find a suitable doctor or facility for later visits.

Despite economic shocks, the lack of coherent healthcare reform before 1997 and chronic under-funding, the Bulgarian health system seems to be coping with the consequences of transition. Use of healthcare is still quite egalitarian and related to need. However, different socio-economic groups use different facilities at different levels of the system. Poorer people access less care and are more likely to remain at the primary care level.

Planned economic reforms and lack of government health spending may widen inequalities. The researchers recommend continued monitoring of equity in healthcare utilisation under the new National Health Insurance system.

Source(s):
‘Access to health care in a system transition: the case of Bulgaria’, International Journal of Health Planning and Management 17: 377-395, by D. Balabanova and M. McKee, 2002

Funded by: European Commission

id21 Research Highlight: 17 March 2003

Further Information:
Dina Balabanova
London School of Hygiene and Tropical Medicine
Keppel Street
London
WC1E 7HT
UK

Contact the contributor: dina.balabanova@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

Other related links:
'The cost of free healthcare: under-the-counter payments in Bulgaria'

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