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What have 13 years of health insurance reforms brought about in Bulgaria? re-appraising the health insurance act of 1998

R. Velichkovski


Introduction: This paper evaluates the financial reforms in the Bulgarian public health care sector. After 1998, when the Bulgarian parliament passed the Health Insurance Act, compulsory contributions for social health insurance became the main source of financing the health care system in the country. They replaced the previous tax-based health care funding mechanism. The aim of this study is to analyze whether the implemen- tation of social health insurance mechanism in Bulgaria brought about the expected improvements in effi- ciency, equity and quality of health care provision and whether it was possible to avoid the potential negative consequences. Material and Methods: The study relies on a review of empirical data and analysis of the exist- ing literature. To collect relevant data, two groups of publications are reviewed: (1) publications prior to the implementation of the social health insurance in Bulgaria that discuss its potential impact; (2) publications af- ter the insurance implementation that investigates the actual impact of this reform. Results: The results sug- gest that social health insurance in Bulgaria brought about certain efficiency improvements in the public health care sector. However, the overall social benefit of its implementation is doubtful. The main reasons for this are related to the ineffective organization of the Bulgarian public health care sector, as well as in the over- all lack of financial resources for health care in the country. The most vulnerable groups are people with dis- abilities and those with no or very low income. Discussion: The replacement of the tax-based financial mechanism by the insurance-based mechanism led to macro-economic stability, although insufficient. In practice, better access to medical services for whole population under the social health insurance cannot be realized. Therefore, more stimuli for efficiency and quality improvement are needed


Social Health Insurance (SHI); Bulgaria; sustainability; efficiency; equity; quality

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R. Velichkovski

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