The paper studies the policy response to the market failures and challenges of healthcare in transition. Bulgaria chose a halfway shift from healthcare services provided entirely by the state to a system with private providers of outpatient services and public providers of inpatient services, both sectors financed mainly by state-run compulsory payroll insurance system. The paper shows the evolution of this reform path to low compliance by both customers (contributors) and service-providers (contractors with the National Health Insurance Fund), which leads to excessive regulations and control, and crowding out of the private sector. The outcome is a system that is increasingly driven by administrative controls at the expense of market incentives. Based on this analysis it identifies the relevant policy implications and opportunities for moving the stalled health reforms out of the institutional impasse.
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