Recent political, social and economic changes in Bulgaria have led to increased demands on health services against a backdrop of falling government revenue. How can the health system make up this budgetary shortfall? What is the extent of ‘under-the-counter’ payments for healthcare? Would patients be prepared to pay formal user fees instead?

Research by the Bulgarian National Centre for Public Health and the London School of Hygiene and Tropical Medicine addressed these issues. They found that informal payments for healthcare services are widespread and that many Bulgarians support the introduction of user fees as part of wide-ranging health sector reforms.

Healthcare systems in Central and Eastern Europe are facing increasing budgetary shortfalls. Following the political changes of 1989, Bulgaria retained a government-funded state health system. However, the government has faced repeated crises, with spending on health declining consistently in the face of national economic collapse. The consequences of reduced health sector funding have been exacerbated by an increased demand for health services.

Successive governments in Bulgaria have been reluctant to introduce formal user fees for health services largely due to fear of a possible political backlash. As a result, financial imbalances have led to an increase in informal under-the-counter payments for healthcare.

The research found that although informal payments are widely regarded as a negative phenomenon, nearly 43 percent of patients have paid for services that are officially free. A substantial majority of Bulgarians are in favour of the introduction of official user fees for health services, although there is resistance from the poor, the old and the chronically ill. The research also suggests that under-the-counter payments for healthcare in Bulgaria:

• have become important sources of extra-budgetary revenue for individual healthcare facilities
• may be essential if health services are to be sustained during this period of transition
• if small, are simply regarded as a sign of gratitude
• have led to a long-term decline in household welfare
• have bred considerable enthusiasm for wider reaching reform of the healthcare system.

Policy measures to address the issue of informal payments for healthcare could include:

• establishing more precisely the frequency, size and characteristics of informal payments
• clamping down on under-the-counter payments and imposing sanctions against staff who accept them
• converting them into formal co-payments
• creating a system that remains responsive to individual patient circumstances without providing the potential for abuse
• introducing wider reforms in the health sector as part of an integrated policy.

Source(s):
‘Under-the-counter payments for health care: evidence from Bulgaria’ by E. Delcheva, D. Balabanova and M. McKee, Health Policy 42 (1997)

Funded by: The Open Society Foundation; The European Union ACE Programme

id21 Research Highlight: 12 February 2001

Further Information:
Evgenia Delcheva
National Centre for Public Heath
14 D Nestorov Blvd., Floor 11
Sofia 1431
Bulgaria

Contact the contributor: health.financing@sf.cit.bg

Martin McKee
European Centre on Health of Societies in Transition
London School of Hygiene and Tropical Medicine
Keppel Street
London
WC1E 7HT
UK

Tel: +44 (0)20 7927 8636
Fax: +44 (0)20 7580 8183
Contact the contributor: martin.mckee@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

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