title: Informal payments for health services: the experience of Bulgaria after 10 years of formal co-payments.
abstract: BACKGROUND
  Informal payments were reported in Bulgaria before and after the introduction of formal co-payments for services included in the basic benefits package in 2000. The aim of our study was to establish the current scale and type of informal payments, as well as public attitudes towards these payments.
  
  
  METHODS
  A nationally representative survey of 1003 individuals was conducted in Bulgaria in July 2010 using face-to-face interviews based on a standardized questionnaire. Respondents were selected through a multi-stage random probability method. The questionnaire included questions on total informal payments (in cash and in kind) for health services used by the respondent during the preceding 12 months.
  
  
  RESULTS
  About 13% of users reported informal payments for outpatient visits and 33% of users reported to have paid informally for hospitalizations. The average amount paid informally for inpatient services was nearly twice higher than that for outpatient services. More than 50% of the sample had negative attitudes towards informal payments in both cash and kind, but about 27% of respondents had a positive attitude towards giving gifts in kind. Regression analysis showed that respondents with higher levels of education had more negative attitudes towards informal cash payments. Positive attitudes towards gifts in kind were more often stated by citizens of larger cities.
  
  
  CONCLUSIONS
  Informal payments continue to exist in Bulgaria irrespective of the formal co-payments introduced in 2000. Although the problem has been recognized in Bulgaria, policies should aim to eliminate the underlying structural reasons for such payments.
authors.affiliation: 1 Department of Health Economics and Management, Faculty of Public Health, Medical University-Varna, Bulgaria 2 Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands elka1105@yahoo.com.
authors.forename: Elka
authors.initials: E
authors.lastname: Atanasova
authors.affiliation: 2 Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
authors.forename: Milena
authors.initials: M
authors.lastname: Pavlova
authors.affiliation: 1 Department of Health Economics and Management, Faculty of Public Health, Medical University-Varna, Bulgaria.
authors.forename: Emanuela
authors.initials: E
authors.lastname: Moutafova
authors.affiliation: 3 European Observatory on Health Systems and Policies, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Bernd
authors.initials: B
authors.lastname: Rechel
authors.affiliation: 2 Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands 4 Top Institute for Evidence-Based Education Research (TIER), Maastricht University, Maastricht, The Netherlands.
authors.forename: Wim
authors.initials: W
authors.lastname: Groot
mesh_terms: D000553:Ambulatory Care / Q000191:economics / Q000706:statistics & numerical data; D002031:Bulgaria; D003695:Delivery of Health Care / Q000191:economics / Q000706:statistics & numerical data; D004522:Educational Status; D005260:Female; D005382:Financing, Personal / Q000379:methods / Q000706:statistics & numerical data*; D019538:Health Care Surveys / Q000379:methods* / Q000706:statistics & numerical data; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006296:Health Services / Q000191:economics* / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic / Q000379:methods; D008297:Male; D011639:Public Opinion; D013222:State Medicine / Q000191:economics / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires