Understanding informal payments for health care: the example of Bulgaria
Introduction
Unlike some of its neighbours, Bulgaria retained a Soviet-model health system during the 1990s, centrally planned and funded from general government revenues. By the middle of the decade it became apparent that the existing funding mechanism was inadequate [1]. Despite a series of one-off financial allocations from central government, supplemented by foreign aid, the system increasingly depended on institutionalised extra-budgetary sources, especially out-of-pocket payments including semi-official fees and ‘under the counter’ payments.
Official attitudes to informal payments have long been ambiguous. A ban that lasted until 1989 was not strictly enforced. Subsequent governments steadfastly avoided taking a view, so that a variety of payments proliferated, acquiring semi-legal status (‘donations’). This was partially formalised by the Decree for the Conditions and Procedure for Payment for Health Care of Patient's Choice in December 1997, defining services for which a fee would be payable. The provisions were, however, vague, with local discretion, and they were considered only a short term solution. In practice, gifts were permitted if they did not lead to abuse.
Better understanding of informal payments is important for several reasons [2], [3]. Firstly, they may be a large component of private health expenditure, rarely included in national health statistics [4]. Better measurement will clarify the extent of private expenditure and the true need for health care funding. Secondly, knowledge of who pays and when will provide information on economic barriers to care. Thirdly, informal payments create perverse incentives, potentially reducing motivation for reform. Finally, informal payments contribute to the informal economy, with implications for the government's ability to raise finances [5].
In a 1994 study, we found widespread informal payments in Bulgaria [6] but that study was limited to recent users of health services, with little information on social and economic circumstances of respondents. This study extends and updates the earlier one, overcoming many of its limitations, by undertaking a large population survey and in-depth qualitative research [7]. We place the findings in the context of other research to develop a conceptual framework for informal payments. We conclude by exploring policy implications.
Section snippets
Methods and definition
The research was conducted in 1997. Data are from two sources. The first is a representative national survey of 1547 individuals aged over 18. In the first of two stages, 200 electoral sectors were selected randomly from the electoral register with probability of selection proportional to size. In each sector, 11 respondents were randomly selected, with eight selected at random for interview (planned sample=1600). Where intended interviewees were unavailable, substitution took place from the
The scale of informal payments in Bulgaria
In the population survey, respondents were asked whether they have ever paid, or given a gift, for a range of services at a state health facility (Table 1). Informal payments appeared relatively familiar, 19% of men and 22% of women having paid or given a gift for at least one service at a state health facility. Gifts were more common than cash payments, 15% of men and 19% of women reporting ever giving a gift compared with 8% of men and of women who reported ever paying cash.
Given the
Discussion
This topic has been the subject of relatively little research in Bulgaria, limiting the scope to validate the results. However, the results do suggest that the frequency of informal payments is somewhat lower than expected from that suggested by previous work [6], [16]. This is, however, a notoriously difficult area to research. It is possible that responses were influenced by perceptions of the semi-illicit nature of the informal transactions. Some underreporting may have occurred due to
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