Primary health care reform in Bulgaria: Impact on the provision of child health services

Most transition countries in Eastern Europe have embarked on reforms in primary health care based on family medicine. This study examines the impact of introducing general practice (GP) system in Bulgaria on child health services.

Methods: The research uses multiple methods and sources of data. A documentary analysis was undertaken of policy documents, reports, laws and regulations relevant to the reform of primary health care. Fifty in-depth interviews were conducted with a wide range of informants: 1) policy makers from governmental departments, non-governmental organizations, professional associations, and academic institutions; 2) health care providers; 3) users of health services. Relevant published research and reports and grey literature were identified and analysed.

Results: A health insurance system and GP-based primary care services were introduced in Bulgaria in the late 1990s. Many physicians, who previously worked as specialists in internal medicine, paediatrics, neurology and other specialties, became GPs. Access to specialist services for adults has been limited by the reform. There are fewer restrictions for referral of children to specialist care. Children have been exempted from health insurance contributions and user fees. Patients have the right to choose their family physician, and many parents prefer to register their children with former paediatric specialists who have become GPs. Evidence from policy reports and in-depth interviews suggests that GPs without specialist training are less qualified to provide quality children's services than the former specialist paediatricians. Although family medicine has been introduced as a specialty, it is perceived as unattractive and many of the GPs have not yet formally qualified as family physicians. In rural and remote areas there are limited opportunities for real choice of a family physician, and patients have reported difficulties in reaching their GP especially out of hours. Large number of patients on the GP registers has limited access for children. In the early years of the reform, insufficient information campaign about the new regulations has limited the access of users from disadvantaged population groups.

Policy implications: Ensuring access to child health services has been one of the priorities of the reform. GPs need to be provided with continuous training to ensure universal quality in the provision of services for children.