The inability to pay for health services in Central and Eastern Europe: evidence from six countries

Title The inability to pay for health services in Central and Eastern Europe: evidence from six countries
Year 2014
Author M. Tambor, M. Pavlova, B. Rechel, S. Golinowska, C. Sowada and W. Groot
DOI 10.1093/eurpub/ckt118
Journal The European Journal of Public Health
Document Type Journal Article
Document Availability Full Text
Classification Policy
Abstract Marzena Tambor1,2, Milena Pavlova2, Bernd Rechel3,4, Stanisława Golinowska1, Christoph Sowada1 and Wim Groot2,51 Faculty of Health Sciences, Department of Health Economics and Social Security, Institute of Public Health, Jagiellonian University Collegium Medicum, Kraków, Poland2 Faculty of Health, Medicine and Life Sciences, Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands3 European Observatory on Health Systems and Policies, London, UK4 London School of Hygiene and Tropical Medicine, London, UK5 Top Institute Evidence-Based Education Research (TIER), Maastricht University, Maastricht, The NetherlandsCorrespondence: Marzena Tambor, Institute of Public Health, Jagiellonian University Collegium Medicum, Grzegorzecka 20, 31-531 Krakow, Poland, Tel: +48 12 4332835, Fax: +48 12 4217447, e-mail: marzenawozniak8{at}wp.plAbstract Background: Out-of-pocket payments for health services constitute a major financial burden for patients in Central and Eastern European (CEE) countries. Individuals who are unable to pay use different coping strategies (e.g. borrowing money or foregoing service utilization), which can have negative consequences on their health and social welfare. This article explores patients’ inability to pay for outpatient and hospital services in six CEE countries: Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine. Methods: The analysis is based on quantitative data collected in 2010 in nationally representative surveys. Two indicators of inability to pay were considered: the need to borrow money or sell assets and foregoing service utilization. Statistical analyses were applied to investigate associations between the indicators of inability to pay and individual characteristics. Results: Patient payments are most common in Bulgaria, Ukraine, Romania and Lithuania and often include informal payments. Romanian and, particularly, Ukrainian patients most often face difficulties to pay for health services (with approximately 40% of Ukrainian payers borrowing money or selling assets to cover hospital payments and approximately 60% of respondents who need care foregoing services). Inability to pay mainly affects those with poor health and low incomes. Conclusion: Widespread patient payments constitute a major financial barrier to health service use in CEE. There is a need to formalize them where they are informal and to take measures to protect vulnerable population groups, especially those with limited possibilities to deal with payment difficulties. © The Author 2013. Published by Oxford University Press on behalf of the European Public Health Association.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact


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