Bulgaria’s high out-of-pocket payments for health care undermines progress towards universal health coverage

Bulgaria has a high incidence of catastrophic health spending compared to other European countries. A new report by WHO/Europe launched today at the Bulgarian parliament reveals that in 2018, 1 in 5 households incurred out-of-pocket payments that exceeded their capacity to pay for health care by at least 40%. Catastrophic health spending may mean a household can no longer afford to meet other basic needs, such as food, housing and electricity.

People paying out of pocket for outpatient medicines is the main driver of catastrophic health spending in Bulgaria. This kind of spending affects poorer households, older people and people living in rural areas the most, and it has increased over time, notes the new report ‘Can people afford to pay for health care? New evidence on financial protection in Bulgaria’.

Although the country has made progress in some areas, out-of-pocket payments accounted for 39% of spending on health in 2019, far above the European Union (EU) average of 21%, says the report.

“Bulgaria’s heavy reliance on out-of-pocket payments for health care is a challenge to universal health coverage – the idea that everyone should be able to use quality health services without experiencing financial hardship,” said Tamás Evetovits, Head of the WHO Barcelona Office for Health Systems Financing. “The report recommends focusing on ways to ensure the National Health Insurance Fund covers the whole population and that it makes exemptions for people who cannot afford to pay co-payments for medicines and other health services.”

“Bulgaria has taken concrete steps to improve access to health care and reduce financial hardship for people using health services, but important gaps in health coverage remain, particularly for households with low incomes,” said Antoniya Dimova, Dean of the Faculty of Public Health at Medical University-Varna and the report’s lead author.

“This new analysis provides a detailed overview of the current situation and identifies a range of options for strengthening financial protection in our health system,” said Anton Tonev, Chair of the Parliamentary Health Committee in Bulgaria.

Gaps in coverage

Reforms introduced in the last 10 years have expanded the range of health benefits provided by the National Health Insurance Fund (NHIF) and to increase the level of government budget funding for the NHIF. Despite these positive developments, the report draws attention to persistent gaps in health coverage.

Nearly 15% of the population is uninsured and can only access a few publicly financed health services. Only those that pay health insurance contributions can access NHIF benefits. The government only pays contributions for people who live in extreme poverty; as a result, many people with low incomes are required to pay contributions but cannot afford to do so.

Co-payments are particularly heavy for outpatient prescriptions, there are no exemptions from co-payments for many medicines, and there is no overall cap on co-payments. This is especially harmful because people must pay for part of the treatment price in Bulgaria through percentage co-payments, and medicine prices are high compared to other EU countries.

Making access to health care affordable for everyone

To improve access to health care and financial protection, policies should focus on finding ways for the NHIF to cover the whole population. The WHO report emphasizes that penalizing people who cannot afford to pay health insurance contributions by restricting their access to health care undermines progress towards universal health coverage. The report’s recommendations to address this include:

• ensure that the NHIF covers people living below the poverty line who are currently not eligible for social support;
• exempting poorer households and people with chronic conditions from co-payments and Replacing percentage co-payments for outpatient medicines with, for example, a small fee per prescription; and
• reducing the price of medicines and increasing the budget allocated to health, as public spending on health is still low in Bulgaria compared to most EU countries – 4% of GDP in 2019 compared to an EU average of 6%.

WHO supports countries in moving towards universal health coverage

Financial protection is central to universal health coverage, which is at the heart of the European Program of Work, WHO/Europe’s strategic framework. Through the WHO Barcelona Office for Health Systems Financing, WHO/Europe monitors financial protection – affordable access to health care – in over 40 countries. Financial protection is an indicator of the Sustainable Development Goals and part of the European Pillar of Social Rights. The WHO Barcelona Office also provides tailored technical assistance to countries to reduce unmet needs and financial hardship by identifying and addressing gaps in coverage.