Financing the health care system in Bulgaria : options and strategies.

The transition to democracy in 1989 forced the Bulgarian health system to change. Falling government revenues and popular demand for a more transparent regime brought pressure for a new system of financing. The process of reform was slow and inconsistent. In part this reflected a lack of political will but there was also an absence of relevant information on the consequences of different options. This thesis seeks to fill this gap by means of an integrated series of studies to analyse the previous system and evaluate the options for change. The research uses literature review, documentary analysis, quantitative research (a population based survey) and qualitative research (interviews and focus groups). The research documents the scale of inequalities in health and health seeking behaviour. Self reported health varies considerably. Utilisation is more evenly distributed, although the poor access less care after allowance for their poorer health. They are also more likely to be cared for in lower tiers in the system. Informal transactions play an important role in the Bulgarian health care system. This has two components. One is a traditional 'culture of gifts which typically imposes no more than minor inconvenience and is not a prerequisite to receive care. A second has appeared more recently. It compensates for genuine shortages and reductions in salaries and does have an impact on access. The existing financing system is regressive and hospital stays can incur considerable expenditure. This is generally found from current income and there was little evidence of ill health leading to impoverishment. This was, however, largely because of the persistence of strong informal support mechanisms. The introduction of social insurance is seen as a solution to the problems of the existing system and receives widespread support, but it is poorly understood. The misconceptions threaten its sustainability. This thesis demonstrates how different methods can be integrated to evaluate a health care financing system and provides important new insights into payment for health care in countries in transition.