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Access to health care in Bulgaria Up to two Million people – many of them of Roma origin - could be excluded from the Bulgarian health service as of January next year. Médecins Sans Frontières published the findings of a recent survey of its patients showing an alarmingly high number who are unaware of the impact of new health policies on their ability to access medical care. Médecins Sans Frontières have witnessed the changes in the health system since the start of reforms five years ago, and has assisted several general practitioners in the Targoviste region to establish their practice in few villages and in the towns of Targoviste and Popovo. Médecins Sans Frontières also run a primary health centre in the Fakulteta area of the capital, Sofia, which services 20,000 patients. The area also holds the largest Roma population in Sofia. The health reforms are based on the move from a tax based to an insurance based system with contributions from both employers and employees. General practitioners are paid from these contributions and to get medical care Bulgarians need to be registered with a general practitioner in their locality. If people cannot pay their contributions, they would have to be deregistered. This in turn affects GPs who would lose income and their ability to maintain their clinics. Many Bulgarians unable to pay their insurance contributions for the last four years could be excluded from the system. In Fakulteta, more than 2,600 people out of the 7,776 patients registered are listed for exclusion if they don’t pay their arrears of contributions by the end of the year. “We demand an amnesty for those who cannot pay back these huge sums” said Ettore Larici. Country Manager of Médecins Sans Frontières in Bulgaria. “Without this amnesty, the health situation for poor people will get much worse than it is now.” We plan to integrate the Fakulteta clinic into the Bulgarian health system, but this will never be possible without an amnesty“ General practitioners, who would run the clinic after the hand over from the medical aid agency, could lose 40 % of their patients, their income and ability to maintain the clinic. This could lead to the total abandonment of the building and the desertion of the area by the doctors. “The Fakulteta health centre is the only clinic for the people in the district.” Information is a key factor in this situation. The survey showed 66 % of the people did not know they were on the list until the Médecins Sans Frontières survey team interviewed them. They were shocked to learn that they need to pay for four to five years back before receiving further health service. Worse still, 77% of those interviewed were unaware of the need to make the monthly insurance contributions and 95% said they could not afford to settle their bill and pay the arrears before the end of the year. (The monthly contribution is 12 Leva or 6 € AUD$10.37 per month, roughly 6% of the minimum wage) Most but not all of the people affected are of Roma origin. Roma usually encounter more problems accessing health care than non-Roma due to poverty, uneven allocation of health facilities across the country as well as communication problems between Roma and health care personnel. The unemployment rate among the Roma is between 70 and 90%. Existing information indicates disturbing inequalities between the Roma health status and the majority of the population: high morbidity and an average life expectancy 10 years less than the average for the rest of the population of the country. People who could lose access to health care are like Kalina, 49 and of Roma origin, is a cleaner earning 235 Leva monthly ($406.00) with an insurance debt of 576 Leva ($996.30), says “where can I find that kind of money! I might as well hang myself right away. There is no work anywhere, my present contract is only until December.” Tania, 52, is a cleaner though, by profession, was an agronomic engineer. She earns 373 Leva ($645) as a cleaner but owes 2150 Leva ($3719) in insurance contributions. She started a company with her husband, registered in her name, and paid social insurance whenever they could. When she started to work as a cleaner she did not realise that, as a company owner, she had to continue paying social insurance for herself. “I am feeling so guilty. It is my fault that I am not insured. But 2000 Leva is too much for me, and it is getting higher, a vicious circle. I just hope I will not get sick.” Vasilka 31 and Stravko 26 are of Roma origin each earning 120 Leva ($207.50) and 110 Leva ($190.20). Vasilka was offered a cleaning job in her son’s school. As he was the only Roma child, she asked for a different posting, fearing discrimination if his Roma status was discovered. This was refused, was unemployed for a year and had no health or social services. Recently she was employed as a field worker for Médecins Sans Frontières which brings in some money. Stravko works as a grave digger but without an official contract. They can now pay the 12 Leva monthly contributions, but their old debt is impossible to pay. They fear going to the insurance institute thinking their few possessions would be confiscated to pay the debt of 1200 $2075.75) Leva. “We will never be able to finish our home and get our son to university if we have to pay back this high amount,” says Starvko. Dorothy Griffiths
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