Access to primary health care services - Fakulteta district
28 September 2004
The Constitution of the Republic of Bulgaria and the health care legislation by virtue of which the healthcare system of Bulgaria is being organised, give the framework of the legal basis for the accessibility and equal rights of all citizens in accessing and utilising health care resources.
Currently two legislative acts regulate the health care system in Bulgaria: the National Health Act, which stipulates that "Every Bulgarian citizen has a right to affordable medical care and health insurance", and the Health Insurance Act, which introduces and regulates the health insurance.
The mandatory health insurance mechanism and the shift from a specialist approach to a more holistic approach by promoting the general practitioner (GP) are the cornerstones of the new system. The insurance covers outpatient basic medical care, and part of specialised medical services and inpatient care.
Roma encounter more problems accessing health care than non-Roma. These barriers are due to poverty, uneven allocation of health facilities and personnel, and communication problems between Roma and health care personnel. Existing information indicate disturbing inequalities between the Roma health status and the majority of the population: high morbidity and an average life expectancy 10 years less than the average for the rest of the population of the country.
Médecins Sans Frontières (MSF) project
In order to contribute resolving some of the major health problems, which were identified during a three month need assessment (January-March 2002) in different Sofia neighbourhoods, MSF decided to implement a Primary health Care project in Fakulteta district.
Accordingly, MSF designed a project to contribute to improve individual, family and community health in Fakulteta District. The project purpose was to establish sustainable and appropriate systems and structures for the provision of health and social services in Fakulteta.
The main results to be achieved by December 2004 were:
To establish, equip and staff a health care centre in order to guarantee access and utilisation of primary health care services and provision of health education.
To provide information about health and social rights and promote intercultural dialogue.
In April 2002 contacts with the Ministry of Health and the Municipality of Krasna Poliana were established and in August 2002 the choice of a building to be rehabilitated, to be used as a medical centre, was made.
By October 2002 all necessary administrative issues had been finalised and funding had been secured from the Austrian Federal Ministry of Foreign Affairs and MSF private funds.
Rehabilitation work started in December 2002 and by the end of May 2003 the building was renovated, furnished and equipped with the participation of the Ministry of Health, which donated medical equipment through the municipality of Krasna Poliana.
Staff was recruited and on the 16th June 2003 the activities started: six General Practitioners (GP) registered with the Health Insurance System provide medical services. A nurse and a midwife employed by MSF ensure data collection to monitor morbidity and social indicators, as well as health promotion and prophylactic activities in particular with pregnant women, mothers and chronically ill patients. MSF also provide resources and staff for proper hygiene and sanitation, and for the general management of the centre.
Free medicines are available for the most needy patients: 2’842 treatments were distributed between June 2003 and August 2004, mainly to children less than 5 years old and elderly more than 60 years old.
GPs managed to register 6,335 patients up to the end of June 2003, 18% being children under the age of 5 years, 28% women in reproductive age (16 to 45 years) but very few old people.
In July 2004, 7,776 patients were registered (23% increase), 15% being children less than 5 years old, 26% women in reproductive age, but old and people suffering from chronic diseases registered in a good number.
Chart 1Click for larger view
An average of 1,400 patients consult every month, 43% being children less than 5 years old and 35% women in reproductive age (chart1).
64% of patients consult for symptoms, the main ones being cough (48%), fever (27%), cold (13%). The main pathologies diagnosed are lower and upper respiratory infection (respectively 31% and 20%). 11% of patients with symptoms do not need pharmaceutical treatment and are sent home after counseling.
36% of people consult for administrative issues such as medical certificates (37%), vaccination (17%), adult or child prophylactic check-ups (17%) or follow-up of chronic diseases (15%).
In November 2003, the team from the "Centre for Sexual Health", an other MSF project, started consultation once a week, covering mainly voluntary HIV counselling and testing, STIs management and family planning.
From January 2004 gynaeco-obstetrical needs were covered with the presence twice a week of a gynaecologist registered with the health insurance funds. In January 2004 also, five field-workers joined the team. They were trained as health promoter and social mediators and visit the population at home.
A "catch-up" vaccination campaign was organised and took place 4-time 1-week between March and June 2004 (see Immunisation coverage, July 2004).
Chart 2Click for larger view
In July and August 2004, a survey on health insurance was conducted among 964 of the 2,664 person registered in the medical centre, who will loose their rights to health care in January 2005 (see Exclusion from health services, August 2004). The employment profile of patients consulting (chart 2) already highlights the vulnerability of the population: only 10% of the patient consulting (29% of the 18-60 years old) has a regular income through fixed contract employment. 20% benefit from social welfare or pension, and 26% (67% of the over 18) live in high precariousness or with meagre social benefits.
Accessibility to health services is the main problem this project seeks to address. Being located in the centre of the district, being staffed with medical and non-medical personnel, who care for the health status of the population and make efforts to reach them, providing drugs for those who cannot get them otherwise, the project addresses the issue of accessibility to primary health care services. However these efforts might be vanished if the threat of deregistration from medical insurance is implemented.