The Library

Regulatory barriers to equity in a health system in transition : a qualitative study in Bulgaria

Tools

Rechel, Boika, Blackburn, Clare, Spencer, Nick and Rechel, Bernd. (2011) Regulatory barriers to equity in a health system in transition : a qualitative study in Bulgaria. BMC Health Services Research, Vol.11 (No.1). p. 219. ISSN 1472-6963

Preview

PDF
WRAP_Spencer_1472-6963-11-219.pdf - Published Version - Requires a PDF viewer such as GSview, Xpdf or Adobe Acrobat Reader
Download (281Kb)

Official URL: http://dx.doi.org/10.1186/1472-6963-11-219

Abstract

Background: Health reforms in Bulgaria have introduced major changes to the financing, delivery and regulation
of health care. As in many other countries of Central and Eastern Europe, these included introducing general
practice, establishing a health insurance system, reorganizing hospital services, and setting up new payment
mechanisms for providers, including patient co-payments. Our study explored perceptions of regulatory barriers to
equity in Bulgarian child health services.
Methods: 50 qualitative in-depth interviews with users, providers and policy-makers concerned with child health
services in Bulgaria, conducted in two villages, one town of 70,000 inhabitants, and the capital Sofia.
Results: The participants in our study reported a variety of regulatory barriers which undermined the principles of
equity and, as far as the health insurance system is concerned, solidarity. These included non-participation in the
compulsory health insurance system, informal payments, and charging user fees to exempted patients. The
participants also reported seemingly unnecessary treatments in the growing private sector. These regulatory failures
were associated with the fast pace of reforms, lack of consultation, inadequate public financing of the health
system, a perceived “commercialization” of medicine, and weak enforcement of legislation. A recurrent theme from
the interviews was the need for better information about patient rights and services covered by the health
insurance system.
Conclusions: Regulatory barriers to equity and compliance in daily practice deserve more attention from policymakers
when embarking on health reforms. New financing sources and an increasing role of the private sector
need to be accompanied by an appropriate and enforceable regulatory framework to control the behavior of
health care providers and ensure equity in access to health services.

Item Type:

Journal Article

Subjects:

R Medicine > RA Public aspects of medicine

Divisions:

Faculty of Social Sciences > School of Health and Social Studies

Library of Congress Subject Headings (LCSH):

Health care reform -- Bulgaria, Child health services -- Bulgaria

Journal or Publication Title:

BMC Health Services Research

Publisher:

BioMed Central Ltd.

ISSN:

1472-6963

Official Date:

17 September 2011

Dates:

Date	Event
17 September 2011	Published

Volume:

Vol.11

Number:

No.1

Page Range:

p. 219

Identification Number:

10.1186/1472-6963-11-219

Status:

Peer Reviewed

Publication Status:

Published

Access rights to Published version:

Open Access

Funder:

Economic and Social Research Council (Great Britain) (ESRC)

References:

1. NSI: Population on 31.12.2010 according to regions, municipalities, place
of residence and sex [in Bulgarian]. Sofia: National Statistical Institute;
2011 [http://www.nsi.bg/otrasal.php?
otr=19&a11=376&a372=377&a373=380#cont], accessed on 311.305.2011.
2. Georgieva L, Salchev P, Dimitrova R, Dimova A, Avdeeva O: Bulgaria:
Health system review. Health Systems in Transition 2007, 9(1):1-156.
3. Popova S, Kerekovska A: A critical review of primary health care reform in
Bulgaria: impact on consumers. International Journal of Consumer Studies
2001, 25(2):123-131.
4. Bulgarian Parliament: Health Insurance Act [In Bulgarian]. State Gazette
1998, 70, (19 June 1998).
5. Delcheva E, Balabanova D, McKee M: Under-the-counter payments for
health care: evidence from Bulgaria. Health Policy 1997, 42(2):89-100.
6. Balabanova D, McKee M: Access to health care in a system transition: the
case of Bulgaria. International Journal of Health Planning and Management
2002, 17(4):377-395.
7. Goddard M, Smith P: Equity of access to health care services: Theory and
evidence from the UK. Social Science and Medicine 2001, 53:1149-1162.
8. Gwatkin D, Bhuiya A, Victora C: Making health systems more equitable.
Lancet 2004, 364:1273-1280.
9. Baldwin R, Cave M: Understanding regulation: theory, strategy, and
practice. Oxford: Oxford University Press; 1999.
10. Wendt C, Frisina L, Rothgang H: Healthcare System Types: A Conceptual
Framework for Comparison. Social Policy & Administration 2009,
43(1):70-90.
11. Rechel B, Thomson S, van Ginneken E: Health Systems in Transition:
Template for authors. Copenhagen: World Health Organization, on behalf
of the European Observatory on Health Systems and Policies; 2010.
12. Rechel B, Spencer N, Blackburn C, Holland R, Rechel B: Impact of health
reforms on child health services in Europe: the case of Bulgaria. Eur J
Public Health 2009.
13. Rechel B, Blackburn CM, Spencer NJ, Rechel B: Access to health care for
Roma children in Central and Eastern Europe: findings from a qualitative
study in Bulgaria. International Journal for Equity in Health 2009, 8:24.
14. Rechel B, Spencer N, Blackburn C, Rechel B: Policy challenges to the
quality of child health services in Bulgaria. International Journal of Health
Planning and Management 2010, 25(4):350-367.
15. Strauss A, Corbin J: Basics of qualitative research: grounded theory
procedures and techniques. London: Sage; 1990.
16. Balabanova D, McKee M: Understanding informal payments for health
care: the example of Bulgaria. Health Policy 2002, 62:243-273.
17. Zdravkova Y: The thin line between co-payment and corruption in the
hospitals. Sega Sofia; 2007, 11-12.
18. MOH: Order No.2 from 1 July 2005 for the conditions and procedures of
provision of health care to foreigners who do not have the rights of
Bulgarian citizens. Ministry of Health, Ministry of Foreign Affairs, Ministry
of Justice. State Gazette 2005, 57, (12 July 2005).
19. World Bank: A decade of experience: lessons learned, implications for
the future. Health, Nutrition and Population in Europe and Central Asia.
Washington, DC: World Bank; 2003.
20. Rechel B, McKee M: Health reform in central and eastern Europe and the
former Soviet Union. Lancet 2009, 374(9696):1186-1195.
21. Preker A, Jakab M, Schneider M: Health financing reforms in central and
eastern Europe and the former Soviet Union: issues, trends and policy
implications. In Funding health care: options for Europe. Edited by: Mossialos
E, Dixon A, Figueras J, Kutzin J. Buckingham. Philadelphia: Open University
Press; 2002:.
22. Waters HR, Hobart J, Forrest CB, Siemens KK, Pittman PM, Murthy A,
Vanderver GB, Anderson GF, Morlock LL: Health Insurance Coverage in
Central and Eastern Europe: Trends and Challenges. Health Affairs 2008,
27(2):478-486.
23. NHIF: Information Bulletin of the National Health Insurance Fund. 2008,
3-4: [http://www.nhif.bg/bg/default.phtml?w=1280&h=994], accessed on 18
September 2008.
24. Georgieva L, Powles J, Genchev G, Salchev P, Poptodorov G: Bulgarian
population in transitional period. Croat Med J 2002, 43(2):240-244.
25. Atanasova E, Pavlova M, Velickovski R, Nikov B, Moutafova E, Groot W: What
have 10 years of health insurance reforms brought about in Bulgaria?
Re-appraising the Health Insurance Act of 1998. Health Policy 2011.
26. Delcheva E: Universal access to healthcare. In Catching up Economic
Development of Bulgaria - Strategy and Realities. Edited by: Angelov I. Sofia:
Institute of Economics of the Bulgarian Academy of Sciences, and Friedrich
Ebert Foundation; 2006:.
27. MOH: Health - priority investment in the future of the nation. Annual
report of the Minister of Health [in Bulgarian]. Sofia, Bulgaria: Ministry of
Health; 2008.
28. Ensor T: Informal payments for health care in transition economies.
Social Science & Medicine 2004, 58(2):237-246.
29. Datzova B: The difficult transition to national health insurance in
Bulgaria. Journal of International Development 2006, 18:425-434.
30. Pavlova M, Groot W, van Merode G: Public attitudes towards patient
payments in Bulgarian public health care sector: results of a household
survey. Health Policy 2002, 59(1):1-24.
31. Pashev K: Corruption in the healthcare sector in Bulgaria. Sofia: Center for
the Study of Democracy; 2007.
32. NHIF: Annual report for the activities of the National Health Insurance
Fund for the year 2006. In Information bulletin of the National Health
Insurance Fund. Volume 3-4. Sofia: National Health Insurance Fund; 2007.
33. Lewis M: Who is Paying for Health Care in Eastern Europe? Issues, Trends
and Policy Implications. Washington, DC: World Bank; 2000.
34. Transparency International: Global Corruption Report 2006. Special Focus:
Corruption and Health. Berlin: Transparency International; 2006.
35. Rose R: Corruption is bad for your health: findings from Central and
Eastern Europe. In Global Corruption Report 2006 Special Focus: Corruption
and Health. Edited by: Transparency International. Berlin: Transparency
International; 2006:39-43.
36. Rose R: Getting Things Done in an Anti-Modern Society: Social Capital
Networks in Russia. Social Capital Initiative Working Paper No 6 Washington
DC: World Bank; 1998.
37. Allin S, Davaki K, Mossialos E: Paying for ‘free’ health care: the conundrum
of informal payments in post-communist Europe. In Global Corruption
Report 2006 Special Focus: Corruption and Health. Edited by: Transparency
International. Berlin: Transparency International; 2006:63-71.
38. Shipochlieva V: Analysis of journalist materials in the central media
regarding health care [In Bulgarian]. National Centre for Public Health, Sofia
2008.