Out-of-pocket payments for health care services in Bulgaria: financial burden and barrier to access.

BACKGROUND: In recent years, Bulgaria has increasingly relied on out-of-pocket payments as one of the main sources of health care financing. However, it is largely unknown whether the official patient charges, combined with informal payments, are affordable for the population. Our study aimed to explore the scale of out-of-pocket payments for health care services and their affordability. METHODS: Data were collected in two nationally representative surveys, conducted in Bulgaria in 2010 and 2011, using face-to-face interviews based on a standardized questionnaire. To select respondents, a multi-stage random probability method was used. The questionnaire included questions on the out-of-pocket payments for health care services used by the respondent during the preceding 12 months. RESULTS: In total, 75.7% (2010) and 84.0% (2011) of outpatient service users reported to have paid out-of-pocket, with 12.6% (2010) and 9.7% (2011) of users reporting informal payments. Of those who had used inpatient services, 66.5% (2010) and 63.1% (2011) reported to have made out-of-pocket payments, with 31.8% (2010) and 18.3% (2011) reporting to have paid informally. We found large inability to pay indicated by the need to borrow money and/or forego services. Regression analysis showed that the inability to pay is especially pronounced among those with poor health status and chronic diseases and those on low household incomes. CONCLUSION: The high level of both formal and informal out-of-pocket payments for health care services in Bulgaria poses a considerable burden for households and undermines access to health services for poorer parts of the population

Hub-and-spoke dispensing models for community pharmacies in Europe

This article explores experiences in Europe with models of "hub-and-spoke" dispensing for community pharmacies. It finds that one of the most common forms of this type of model is automated "multi-dose dispensing" for older people who take multiple medicines, either in nursing homes or at home. Although now firmly established in the Nordic countries and the Netherlands, evidence on outcomes and costs is limited and does not allow firm conclusions. There is some indication that multi-dose dispensing might reduce overall drug use and improve treatment adherence, but would increase inappropriate drug use and result in fewer changes in drug treatment. Evidence on cost implications is missing so far

How to enhance the integration of primary care and public health? Approaches, facilitating factors and policy options

There are universal calls for improved integration between public health and primary care, but it is less clear how this can be achieved – and, in practice, integration is often hampered by the ways in which both sectors and services are organized and financed, as well as through other obstacles. Interaction between public health and primary care is complex. Some functions are more clearly situated in one of the two domains, while others belong to both of them. For example, primary care often performs some public health functions (e.g. screening, immunization and interventions to support healthy lifestyles), while public health helps to make the provision of primary care more effective (e.g. through surveillance, planning and evaluation). Enhanced integration between these two domains can bring health and other benefits (although these are not clearly documented in the literature), but can also bring risks, of which policy-makers should be mindful, such as placing an additional burden on already limited (financial, human and other) resources. Much of the recent academic literature on the integration of public health and primary care is from the United States, but there are also many examples from Europe. We cluster the examples into five categories, but these are not mutually exclusive, and many interventions (such as increased adoption of electronic patients records) could fall under more than one category: 1. Coordinating health care services for individuals, e.g. by bringing clinical and public health professionals together at one site. 2. Applying a population perspective to clinical practice, e.g. by using population-based information to enhance clinical decision-making. 3. Identifying and addressing community health problems, e.g. by using clinical opportunities to identify and address underlying causes of health problems. 4. Strengthening health promotion and disease prevention, e.g. through education, advocacy for health-related laws or regulations. 5. Collaborating around policy, training and research, e.g. by engaging in cross-sectoral education and training, or conducting cross-sectoral research. There are organizational models of primary care that are conducive to integration with public health, as well as systemic, organizational and interpersonal factors that can facilitate integration and provide a useful checklist for integration attempts at either the national or regional level. Which model comes into consideration and which factors play a key role will depend very much on the specific country context and the organizational set-up of primary care and public health. Yet, a systematic approach to improved integration can be broadly guided by the following principles, which have been identified as essential to success: a shared goal of population health improvement; community engagement; aligned leadership; sustainability; and sharing and collaborative use of data and analysis

HIV/AIDS discourses in Kyrgyzstan's policy arena.

This article explores the major discourses on HIV/AIDS in the policy arena in Kyrgyzstan, a former Soviet country in Central Asia that has experienced a rapid rise in HIV infections since the early 2000s. Based on an analysis of policy documents and 54 semi-structured in-depth interviews with key stakeholders in the area of HIV/AIDS policies in Kyrgyzstan, we distinguish a number of key discourses, competing for legitimacy and authority. While some of these discourses have been used in other countries (such as those presenting HIV/AIDS as a biomedical, social or moral issue), others are more specific to Kyrgyzstan (such as a discourse presenting the country as a regional pioneer in HIV/AIDS prevention efforts). Our analysis shows how HIV/AIDS discourses in the policy arena overlap and complement each other and how stakeholders employ a number of tools and strategies to promote and secure their agendas and positions of power. Our findings help to better understand HIV/AIDS discourses in Kyrgyzstan and elsewhere. They highlight the importance of understanding which discourses are prevailing, who drives them and why, how they change over time, and how they can be framed to achieve policy objectives

Funding for public health in Europe in decline?

Concerns have been raised in recent years in several European countries over cutbacks to funding for public health. This article explores how widespread the problem is, bringing together available information on funding for public health in Europe and the effects of the economic crisis. It is based on a review of academic and grey literature and of available databases, detailed case studies of nine European countries (England, France, Germany, Italy, the Netherlands, Slovenia, Sweden, Poland, and the Republic of Moldova) and in-depth interviews. The findings highlight difficulties in establishing accurate estimates of spending on public health, but also point to cutbacks in many countries and an overall declining share of health expenditure going to public health. Public health seems to have been particularly vulnerable to funding cuts. However, the decline is not inevitable and there are examples of countries that have chosen to retain or increase their investment in public health

Dispensing emotions: Norwegian community nurses' handling of diversity in a changing organizational context

Since the mid-1990s, public sector health care services in Norway have been restructured, in line with New Public Management ideas. This restructuring has coincided with demographic changes that have led to a more culturally diverse patient population. Both developments have created new challenges for community nurses in managing their work. This qualitative study applies the concept of “emotional labor” to examine nurses' experiences in working with ethnic minority patients in the context of pressures arising from organizational reforms. The analysis sheds light on the nurses' attempts to comply with system-induced efficiency considerations, while catering to the special situation of patients with language barriers and unfamiliar cultural traditions. The article demonstrates how efficiency requirements and time constraints either aggravate the nurses' insecurity in dealing with minority patients or, in some cases, compel them to assume more work responsibilities so as to mitigate the effects of such constraints

Barriers to accessing adequate maternal care in Central and Eastern European countries: A systematic literature review.

Maternal health outcomes in Central and Eastern Europe (CEE) compare unfavorable with those in Western Europe, despite macro-indicators that suggest well-designed maternal care systems. However, macro-indicators at the system level only capture capacity, funding and utilization of care and not the actual allocation of financial and human resources, the quality of care and access to it. It is these latter which are problematic in the CEE region. In this study service-related indicators of access to maternal care in CEE are examined. These include availability, appropriateness, affordability, approachability and acceptability of maternal care. This study uses a qualitative systematic literature review, analyzing information of peer-reviewed articles published since 2004. Other inclusion criteria included language, setting and publication purpose. The included articles were analyzed using a framework analysis technique and quality was assessed using standardized evaluation checklists. Results indicate improvements in maternal care. However, availability of care is limited by outdated equipment and training curricula, and the lack of professionals and pharmaceuticals. Geographical distance to healthcare institutions, inappropriate communication of providers and waiting times are the main approachability barriers. Some mothers are unaware of the importance of care or are discouraged to utilize healthcare services because of cultural aspects. Finally, a major barrier in accessing maternal care in the CEE is the inability to pay for it. Our findings indicate that major gaps in evidence exist and that more representative and better quality data should be collected. Governments in CEE countries need to establish a reliable system for measuring and monitoring a suitable set of indicators, as well as deal with the general social and economic problem of informality. Medical curricula in the CEE region need to be overhauled and there should be a focus on improving the allocation of medical staff and institutions as well as protecting vulnerable population groups to ensure universal access to care

Catastrophic Health Care Expenditure among Older People with Chronic Diseases in 15 European Countries.

INTRODUCTION: It is well-known that the prevalence of chronic diseases is high among older people, especially those who are poor. Moreover, chronic diseases can result in catastrophic health expenditure. The relationship between chronic diseases and their financial burden on households is thus double-sided, as financial difficulties can give rise to, and result from, chronic diseases. Our aim was to examine the levels of catastrophic health expenditure imposed by private out-of-pocket payments among older people diagnosed with diabetes mellitus, cardiovascular diseases and cancer in 15 European countries. METHODS: The SHARE dataset for individuals aged 50+ and their households, collected in 2010-2012 was used. The total number of participants included in this study was N = 51,661. The sample consisted of 43.8% male and 56.2% female participants. The average age was 67 years. We applied an instrumental variable approach for binary instrumented variables known as a treatment-effect model. RESULTS: We found that being diagnosed with diabetes mellitus and cardiovascular diseases was associated with catastrophic health expenditure among older people even in comparatively wealthy countries with developed risk-pooling mechanisms. When compared to the Netherlands (the country with the lowest share of out-of-pocket payments as a percentage of total health expenditure in our study), older people diagnosed with diabetes mellitus in Portugal, Poland, Denmark, Italy, Switzerland, Belgium, the Czech Republic and Hungary were more likely to experience catastrophic health expenditure. Similar results were observed for diagnosed cardiovascular diseases. In contrast, cancer was not associated with catastrophic health expenditure. DISCUSSION: Our study shows that older people with diagnosed chronic diseases face catastrophic health expenditure even in some of the wealthiest countries in Europe. The effect differs across chronic diseases and countries. This may be due to different socio-economic contexts, but also due to the specific characteristics of the different health systems. In view of the ageing of European populations, it will be crucial to strengthen the mechanisms for financial protection for older people with chronic diseases