Since the start of the transition period in Bulgaria (1989) all social systems have undergone dramatic changes. The process of transition has increased the social inequalities in the society by bringing a vast part of the population into poverty and at the same time shattering the social security systems. Moreover, Bulgaria’s transition phase has exhibited particular influence over the health care sector and has led to various quality, equity and efficiency problems and substantial decrease in health outcomes (Koulaksazov et al., 2003, p.6-7) During the economic crises in 1996-1997 the living standards of the majority of the population dropped substantially. At the end of 1997 65.5 % of the population had incomes under the social minimum (Ministry of Health, 2001, p.18). Furthermore, surveys on informal payments for health services in 1998 – 1999 show figures with up to 51 % of the respondents paying for services which are officially free (Ministry of Health, 2001, Balabanova and McKee, 2002, p.264). These numbers show worsening health status of the population, combined with both impoverishment and an increase in out-of-pocket payments for health care, pointing towards serious equity issues. Since the start of the transition in 1989, the health sector in Bulgaria has continued to be characterised by the inherited Semashko model. The financial protection in the health care was severely undermined. The constitutional right of citizens to “medical insurance guaranteeing them affordable medical care”(1991, Article 52, s.a. 1) was disregarded. The reforms introduced only at the end of the 1990’s aimed at improving the health of the nation by building accessibility, equity, and solidarity (Ministry of Health, 2001, p.31). Equity related problems in the health sector are numerous and this study focuses on the ability of the reformed health care system to address the issues concerning equity in financing and delivery of health care during the transition phase. The research is based on analysis of the Living Standards Measurement Surveys of the World Bank
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