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Compatibility with popular values is an important factor that must be considered when reforming the mix of health care financing methods. Solidarity remains strong in Bulgaria with widespread support for public and universal free health care. Nevertheless there are concerns over system sustainability and equity, and misconceptions about different financing systems. Researchers sought to discover what general principles and practical aspects of health financing reform were important to the population. The survey, focus groups and in-depth interviews were conducted in 1997 before large-scale reforms were initiated in the Bulgarian health system. The researchers tested the popularity of taxation, social and voluntary insurance, and co-payments. Overall, the principle of solidarity was important, with a majority of respondents stating that payments should be differentiated according to ability to pay with exemptions or reduced user fees for certain disadvantaged groups. A majority (55% of men and 52% of women) favoured a universal system of social insurance (SI), with monthly contributions paid into a health fund. The most popular mode of payment for health care was a compulsory monthly contribution calculated as a percentage of income. The level of dissatisfaction with the old tax-based system was similar among both users and physicians, although a significant split emerged between those who favoured adapting the inherited model and those who saw it completely obsolete. A common concern was the perceived lack of funding. Opinions were divided over the fairness of the old system, with some questioning the meaning of ‘fair’ in a context of low quality of service and poor working conditions. Where there was public acceptance of the tax-based system, this appeared to be based on tradition and resistance to change, accompanied by a lack of trust in reforms. SI was considered:
A two-tier system, in which the rich obtain a ‘luxury’ service in exchange for higher payment, was regarded as practical and acceptable. State regulated voluntary insurance covering services on top of compulsory insurance, although less preferable than SI, was far more acceptable than out-of-pocket payment. Out-of-pocket payments in the public sector, especially for pharmaceuticals, were seen as unaffordable and unacceptable, especially under SI, although some see direct payment to providers as a convenience. On the basis of popular preference there is a strong argument for retaining significant state involvement in health care financing and provision, ranging from the provision of safety-nets or subsidies, to performing a regulatory function. The clear preference was for an equitable, transparent and accountable health insurance system based on principles of solidarity. However, support for radical change was uneven, with those who had suffered most through transition favouring the familiar tax-based models rather than new financing mechanisms. Unrealistic expectations of health insurance indicate that there is a need for a public information campaign setting out costs, benefits and pitfalls. Continued monitoring of the evolving perspectives of key stakeholders is important as new evidence of a declining attractiveness of SI emerge. It is essential that a reform process remains in touch with a population's overriding values, practical concerns and needs. Source(s): Funded by: UK Department for International Development; EU ACE Programme id21 Research Highlight: 4 March 2004
Further Information: Tel:
+44 (0) 20 7927 2929 London School of Hygiene and Tropical Medicine, UK
European Centre on Health of Societies in Transition Other related links:
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