Regulatory barriers to equity in a health system in transition : a qualitative study in Bulgaria

Background: Health reforms in Bulgaria have introduced major changes to the financing, delivery and regulation of health care. As in many other countries of Central and Eastern Europe, these included introducing general practice, establishing a health insurance system, reorganizing hospital services, and setting up new payment mechanisms for providers, including patient co-payments. Our study explored perceptions of regulatory barriers to equity in Bulgarian child health services. Methods: 50 qualitative in-depth interviews with users, providers and policy-makers concerned with child health services in Bulgaria, conducted in two villages, one town of 70,000 inhabitants, and the capital Sofia. Results: The participants in our study reported a variety of regulatory barriers which undermined the principles of equity and, as far as the health insurance system is concerned, solidarity. These included non-participation in the compulsory health insurance system, informal payments, and charging user fees to exempted patients. The participants also reported seemingly unnecessary treatments in the growing private sector. These regulatory failures were associated with the fast pace of reforms, lack of consultation, inadequate public financing of the health system, a perceived “commercialization” of medicine, and weak enforcement of legislation. A recurrent theme from the interviews was the need for better information about patient rights and services covered by the health insurance system. Conclusions: Regulatory barriers to equity and compliance in daily practice deserve more attention from policymakers when embarking on health reforms. New financing sources and an increasing role of the private sector need to be accompanied by an appropriate and enforceable regulatory framework to control the behavior of health care providers and ensure equity in access to health services

INDIVIDUALISM, COLLECTIVISM AND THE MARKETIZATION OF SOCIAL SECURITY: Chile and China Compared

Ideological beliefs are of central importance in current debates about the marketization of social security. However, developments in Chile and China suggest that the conventional individualist-collectivist dichotomy, which has framed ideological debates on social security, fails to capture the complexities of ideological differences as well as the imperative of economic development which appears to be driving social security policy in both countries. Examining events in these countries, it is suggested that the individualist-collectivist dichotomy needs to be reconsidered. It is also argued at a normative level that these ideologies no longer provide a viable basis for social security policy, and that the "developmentalist" approach emerging in China merits further scrutiny. Copyright 2002 by The Policy Studies Organization.