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Exclusion from health care services Fakulteta district, Bulgaria

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Since more than four years now, the Bulgarian health system has been changing its model from one fully subsidised by the state through general taxation, to one almost entirely financed on the basis of the principle of insurance. Accordingly the National health Insurance Fund (NHIF) was established in 1999 and operational in July 2000. The health insurance is compulsory for everyone and is calculated as 6% of the salary; "voluntary contribution" (for people whose contribution is not covered by an employer or the state) is of 12 Leva per person per month. Pensioners, registered unemployed who have rights to social benefits, children below the age of 18 years and students are insured by the state. During the first years of the new system, the compulsory payments of the fees was not enforced nor controlled and people continued to have access to health services. The National Health Insurance decided to streamline the situation and requested the exclusion of people who didn't pay their contribution, each and every month, since the beginning of the reform. According to some estimates those are between 350'000 and two million, many of them owing amounts corresponding to months or years of income (see Testimonial). 7,776 patients are registered with the six general practitioner of Fakulteta medical centre as per today. 2,664 (34%) are on "the list" of people threatened to be de-registered, if they do not pay their arrears of contributions by the end of the year.

The survey

During the month of July and August 964 people, age 20 to 61, on "the list", with the biggest amounts to reimburse, were interviewed using a structured questionnaire. The sample size correspond to 36% of "the list" of the people registered in the medical centre supported by MSF, who will no longer be covered by the health insurance starting from January 2005. The objective of the survey was to understand who were these people who did not pay their contribution, why they did not pay and what they intended to do about it. Another aspect we wanted to evaluate was the awareness of the people in "the list" about their knowledge of issue of compulsory health insurance.

66% of the people claimed they did not know they were in the list until our team of field-workers doing the interviews told them. Many people had heard that there were some problems with the insurance but they did not know that they were concerned. There were some discussions on television but, it was discussions between experts and they did not understand anything. Some people received letters from the NHIF; they understood that they had arrears to pay but they did not understand they would lose access to free health care if they didn't settle the bill. People in the list are young (40% between 20 and 29 years old) in comparison with the age of the patients registered with the GPs, and with low or no income. People who knew they were in the list were older than those who did not know. The reason is that more older people consulted their GP in the past few months, and had been explained (and understood) that they were in the list.

Most of the 41% of those who say they do not understand why they will be excluded, receive some social aid and thought that it was enough to be insured. Some of them work or have worked during most of the period concerned and thought their employer was paying the insurance fees. 57% are shocked to learn they need to pay for 4 to 5 years arrears. There is a lot of incomprehension and feeling of injustice in front of a situation that people have the feeling not to control.

More than four years after the beginning of the implementation of the new health system, 77% of the people interviewed claim they don't know they have to pay 12 Leva per month as a contribution to the health system. Asked whether they would settle their bill before December 2004, 95% declared that they would not, because they cannot afford to do it; reimbursement would need to be staggered over an unrealistic number of years for the people to be able to pay.   When asked where to go to settle the bill 74% of the interviewees gave a wrong answer or said they did not know. There was a huge difference in the answers among the people who knew they were in the list (52% knew as well where to pay) and those who did not know they were in the list (13% knew where to pay). The information given by the GP was the only one understood.

Conclusion and recommendations

From the analysis of the data collected it appears quite clearly that the problems are of various nature. Communication No surprisingly, inadequate communication is the core problem to the existing situation. People do not know, do not understand, don't trust or do not believe. Starting from the beginning of the health reform, the information provided to the public about the radical change in the system has been indigestible. People didn't understand which procedures guaranteed them health services, what they had to do, or not to do, in any given situation. Isolated people and people with low education had very little chance to grasp the subtlety of the new system. There is a need for clear, simple, customised information.  Furthermore, today, people who would like, and could, settle their bill and start again on good grounds, face a so cumbersome and time-consuming process, that it doesn't facilitate nor stimulate them to comply. There is a need for clear, simple, rapid, user friendly administration procedures, to clear up the board and to avoid being in the same situation in four years time. We would like to question the legitimacy and the meaning of the request of the NHIF to reimburse five years arrears. It is not clear if this is legal, but can an institution wait four years to notify people that they are out of the track? Shouldn't the guild of the current situation be shared between the service users, the insurance, and the social and health authorities in general? Anyway, as a matter of fact the majority of the remaining designed culprits, the insured, cannot pay and will never be able to pay. Accordingly we demand an amnesty to the payment of the arrears, which is an insurmountable obstacle to the normalisation of the situation, and that a system be put in place to inform people rapidly and adequately when they don't comply with the system.