Balabanova Dina, McKee Martin
London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
Int J Health Plann Manage. 2002 Oct-Dec;17(4):377-95. doi: 10.1002/hpm.687.
Throughout the 1990s, the Soviet-style model in central and eastern Europe that provided free health services has been subject to radical reforms. Socio-economic inequalities have also increased but there is little information on inequalities in health care utilization. This paper examines the pattern of illness behaviour in Bulgaria, seeking evidence of inequalities in access to services and eliciting users' pathways to care.
Analysis drew on a representative population survey in Bulgaria (1997). The financial determinants of service use were tested in a multivariate model adjusted first for age, and then for age, marital status and self-reported health. In-depth interviews with users and providers addressed pathways to care, use of connections and other informal strategies to obtain care.
As expected, rates of illness vary with income, with highest rates among the poor. After adjustment for illness, consultation rates are relatively equal across income levels, with the exception of worse-off women who tend to consult more. For first contact, there are few differences according to income, with the better off preferring secondary level. Pathways slightly differ, with women more often treated in primary care. Private sector utilization is low. Qualitative research reveals well-established strategies to obtain more advanced care, including use of connections, informal payments and use of emergency services.
An apparent lack of inequalities in access to care conceals a more complex picture in which income and gender influence the pathways taken through the system.
在整个20世纪90年代，中东欧提供免费医疗服务的苏联式模式经历了彻底改革。社会经济不平等现象也有所加剧，但关于医疗服务利用方面不平等的信息却很少。本文考察了保加利亚的疾病行为模式，寻找获得服务方面不平等的证据，并探究使用者的就医途径。
分析采用了保加利亚具有代表性的人口调查（1997年）数据。在一个多变量模型中检验了服务利用的经济决定因素，该模型首先对年龄进行了调整，然后又对年龄、婚姻状况和自我报告的健康状况进行了调整。对使用者和提供者进行的深入访谈涉及就医途径、利用人脉关系及其他获取医疗服务的非正式策略。
正如预期的那样，发病率随收入而变化，穷人中的发病率最高。在对疾病进行调整后，各收入水平的就诊率相对均等，但贫困女性的就诊率往往更高。在首次就诊方面，收入差异不大，较富裕者更倾向于选择二级医疗机构。就医途径略有不同，女性更多地在初级医疗保健机构接受治疗。私营部门的利用率较低。定性研究揭示了一些既定的获取更高级医疗服务的策略，包括利用人脉关系、进行非正式支付以及使用急诊服务。
在获得医疗服务方面明显不存在不平等现象，这掩盖了一个更为复杂的情况，即收入和性别会影响在整个医疗体系中的就医途径。
