Bulgaria takes up a leading position in terms of child mortality in the European Union. The risk of every child born in our country dying before the age of five is 70% higher than the average for the EU. According to Eurostat data from 2020, 15.5 of every thousand have died in the past year.
This is a sign that the population‘s health should be prioritized by guaranteeing accessible healthcare for everybody and for the most vulnerable ones in particular – children and senior citizens. In addition to health insurance and outpatient and inpatient medical care, another extremely important factor for achieving accessible healthcare is accessible medication.
Providing free medication for children under 3 years old would guarantee effective and available healthcare in early age. This way all children would have an equal opportunity to receive proper medical care during the first three years of their life which are extremely critical for their development. In the long term, this investment would save expenses, it would contribute to handling the country’s severe demographic crisis and would make possible a better and more prosperous future for the population.
The high prices of medicine are the most common reason for children not to take prescribed drugs. Parents from low-income households face many difficulties in ensuring the regular intake of necessary drugs and the consequences of not following doctors’ prescription are:
· an increase in hospitalizations and complications
· more frequent emergency hospitalizations
· more frequent doctors’ visits
· depriving oneself from basic needs such as food because of the price of the medication
· higher mortality rates
Along with the COVID-19 crisis, health and social inequalities have grown worldwide, being most critical in countries with a higher rate of the population living at risk of poverty. In Bulgaria – the poorest country in the EU, more than 1/3 of the children live at risk of poverty (over 570 000, Eurostat, 2018) in conditions of deficiencies in terms of health and social life which will leave a permanent mark on their future development. The negative rate of natural increase of -7 out of 1000 citizens exists as a stable tendency in the country (Eurostat, 2020). That is why services and policies which guarantee the health of the population, especially the youngest and the oldest, are of high-priority.
The Ministry of Health and The Parliamentary Healthcare Committee define maternal and child health as a national priority and as a key investment for a better future for the country. It is also pointed out as a solution to the severe demographic crisis. Nevertheless, the efforts and actions in this direction are not effective enough and there are no policy improvements which could serve as a long-term solution of these issues.
Is healthcare really accessible for pregnant women and children in Bulgaria?
Pregnant women and mothers of children up to one year of age have access to health care by law (Ordinance № 26 from 14th June 2007 will be discussed in another article) and minors from age 0 to 18 have health insurance and do not have to pay the “user fee for outpatient and inpatient medical and dental care” (NHIF). In addition, “all general practitioners can refer children up to the age of 18 for unlimited consultation with a doctor with a degree in Pediatrics, Pediatric Gastroenterology , Pediatric Cardiology, etc.” (NHIF). The lack of a national drug policy stands out as a major flaw on the path to a more affordable healthcare system.
The currently operating mechanisms for registration, pricing and subsidization of medicines do not provide an adequate ratio of quality-price of the NHIF and contribute to the inefficiency of the healthcare sector and the high mortality rate. Although there are positive lists of medicines that NHIF covers fully or partially, data show that in Bulgaria, the poorest country in the EU, direct payments (surcharge for medication or outpatient care) are the highest – 46.6%, nearly three times more than the average direct payments for health in the EU 15.8%. In Bulgaria people set aside around 6% of their monthly income for medication, more than any other EU member state.
In the field of maternal and child health there is also a serious shortage of funds to cover medication for children. According to a sociological study ordered by the Bulgarian Pediatric Association ( BPA) “About BGN 100 per month is spent on a child under 1 year of age, half of which is for medicine” (Nenova, 2019). Only about 11% to 13% of the NHIF budget is for children’s health (Nenova, 2019) and a mere 5% of all the funds that NHIF spends annually to fully or partially cover the costs for medicine for children (Nenova, 2019). Due to the demographic and economic crisis in certain regions in the country, there are areas in which there is a significant shortage of pharmacies, pediatricians and medical practitioners specialized in pediatrics, which also means additional expenses for transport when in need of a consultation with a specialist.
The lack of a national drug policy and the consequences for children
Although there is access to medical care and specialists, without a stable national drug policy, drugs for outpatient medical care remain inaccessible and healthcare for mothers and children – insufficient and ineffective.
For families living in poverty the lack of funds for covering the necessary drugs leads to complications and chronic diseases, which could otherwise be treated easily and successfully. For example, a major problem with children under the age of 3 is the high rate of pulmonary diseases (pneumonia, chronic bronchitis, 11.4‰ and 7.9‰ respectively). For children living in poverty, respiratory infections are caused by poor living conditions and often turn into chronic conditions which reflect on their development and overall health.
Examples from the European Union – strategies and policies which reduce inequalities in maternal and child healthcare
Most EU countries enforce legal frameworks which aim to reduce prices for medication and to make them as accessible as possible for all consumers. The most popular approach is a differentiated VAT rate for medication. It is a fact that in European countries at an average standard VAT of 20,5% the average rate for medication is 7,7% and it varies between 0 and 25%. Only Bulgaria, Denmark and Germany have no differentiated VAT rate for medication. In Germany, however, medication for everyone aged 0-18 is free and in Denmark there are significant reductions.
Beyond tax rates, other approaches for reducing the pricing of medication and ensuring equal access is: buying in bulk through joint orders from several institutions/countries; limiting expenses for insured patients or the limit values of the acceptable cost per episode of treatment; limiting marketing and advertising costs, which are a significant expense and are only intended to raise consumption; redirection to cheaper generic drugs; price control: mainly of factory and retail prices; encouraging rational use.
Reducing the tax rate seems to be the most popular approach amongst state members but given the high risk of poverty and child mortality in Bulgaria the more suitable approach would be a combination of implementing free medication for children under 3 years of age and some of the approaches for lowering the price of drugs.
A good example in Bulgaria as well
Since 2016, a service providing access to free medication for pregnant women and children under 2 years of age from families at risk has been tested in Bulgaria. Within the program Family-Nurse Partnership, implemented by the Trust for Social Achievement foundation, vulnerable families are assisted with patron care in Sofia and Plovdiv in the preparation for birth and in the care of their first child. In addition to the structured and individual expert support which the families receive from trained family nurses, the program also provides funds to cover medicine.
The team of nurses in the Family-Nurse Partnership, as well as the consultants, observe that it is impossible for families living in poverty to set aside funds for medication. For this reason, it is too often that infections and other treatable conditions in both mothers and children turn into chronic illnesses which are difficult to treat and lead to serious potential complications. This has a negative effect not only on the health of these families but for the health system in general which, at a later stage, will have to cover the treatment for these chronic illnesses. The financial support covers drugs which successfully and effectively treat respiratory infections in children, and fungal and other infections in pregnant women.
On the verge of the expiration of the National Health Strategy 2020, the Trust for Social Achievement foundation draws attention to the need to evaluate its execution and to create recommendations for its new strategy – with the participation of a wide range of stakeholders (National Health Strategy 2020, Ministry of Health). Against the background of the stated goals and priorities in the expiring document, issues and inequalities in maternal and child health remain and the child mortality rate continues to be the highest in the EU. Free medication for children under the age of 3 is a recommendation for improving the development of the youngest, reducing high infant mortality and ensuring a healthier adolescent generation.