ETHICAL DIMENSIONS OF WILLINGNESS TO PAY FOR MEDICAL CARE IN BULGARIA

Regardless of what both patients and medical professionals might think, nowadays there is no free medicine. The need of changing the pattern is emphasized and people should become more responsible for their own health. The aim is to find a connection between the trust in GPs, prophylactic check-ups, new methods of treatment and the willingness of patients to pay for the received medical services. Material and Method: A questionnaire was prepared for the purposes of the study. The methods utilized were a direct individual anonymous questionnaire, statistical – descriptive, analytical (Chi-square). The answers were examined and statistically processed according to age, gender and education level of the participants. Results: 1. The results regarding the trust in GP is very unconvincing – only 14,5 % believe in their GP. 2. The percentage of believers in prophylactic check-ups is high 57,9%. 3.The percentage of those who believe in the new methods and means for treatment is high, over 80%, while no difference is found with respect to the patients’ education level. 4. The patients often (86%) pay for the treatment of a specialist. 5. People with higher education more readily pay for medical care. Conclusions: 1. The lack of trust in GP combined with the strong belief in prophylactic check ups and the new methods for diagnostic and treatment of diseases lead to higher expectations of patients towards the medical services and their readiness to pay for these services. 2. The patients indicate readiness to pay for medical services which is a part of the patients’ readiness to take care for their own health.


Introduction
Everyone wants all his needs to be satisfied by the society. The main question is which is the best proportion between personal and public needs (1,2,3). In the years of reform the need of Http://www.granthaalayah.com ©International Journal of Research -GRANTHAALAYAH [517] changing the pattern and that people should become more responsible for their own health (4, 8,9).
Medical values are access to medical help, equality and justice, human attitude and sympathy toward the patient, autonomy of the patient and free choice of doctor and also clinical freedom for the doctors. Unfortunately there is no Health system in which all of the values to be realized in maximum capacity and the problem with the access to medical help to be solved (6,7,11). That problem is very important factor to estimate the quality of the Healthcare system. It is important to realize that there couldn't be high quality of medical care in low prices for all people who need it (3,5,11). It should be guaranteed both to patients and doctors the right of free choice. The clinical freedom of doctors is not realistic. Only few diseases are treated for free. To dull the conflicts due to distribution of funds some criteria and rules are accepted. Regardless of what both patients and medical professionals might think, nowadays there is no free medicine (11).

The aim
The aim is to find a connection between the trust in GPs, prophylactic check-ups, new methods of treatment and the readiness of patients to pay for the received medical services up to their age, gender and education.

Material and method
A questionnaire was prepared for the purposes of the study. The methods utilized were a direct individual anonymous questionnaire, statisticaldescriptive, analytical (Chi-square). The answers were examined and statistically processed according to age, gender and education level of the participants. 385 questionnaries were collected for a period of two monthsworkers in a supermarket, advertising agency, printer agency, school, friends and patients with different professions, neighbors.

The quest
Question №

Question №1 Do you believe in your GP?
The result of trust is very unconvincingonly 14,5 % trust. The high % of non believers is almost the half -41,3%. The total % of non believers and ones who are seeking for another opinion is 85,5% ( fig. №1).  According to age: for the youngest 18-24 years old around 70% do not believe in their GP/GDP. Up to the oldest group over 60 years old -42 % do not believe. The third answer -"seeking another opinion" is preferable in the groups 25-44and 45-59-years -50 % in each group. That may be due to the fact that in that age is the highest activity and highest number of workers which makes their financial possibilities higher and they are able to seek another opinion (c2= 51,687; р=0,00).  According to sex: With 10 % more the women than the men look for another opinion, but 13 % more of the women than the men do not believe in their GP/GDP (c2= 7,501; р=0,024).  According to education: The mistrust (answer "No") is shown in 60% of people with secondary education, while 50% of ones with higher education prefer to seek another opinion (c2= 22,728; р=0,00).   According to age: 74,7% in the age of 25-44 years old believe in prophylaxis followed by 60+ years old of whom 60% also believe. 18-24 years old are the one who believes lessonly 31,7%. Average -only around 10% of all groups do not believe in prophylaxis. 59,8% of the group of 18-24 years old do not pay attention to prophylaxis, for the other groups the average percentage is 23% (c2= 46,416; р=0,000).  Sex: In contrast to men the bigger percent of women do believe in prophylaxis. 29,1% of women do not pay attention to it, where men 39,1% do not pay attention to prophylaxis (c2= 11,606; р=0,003).  Education: More than 50 % with secondary education do not pay attention to prophylaxis, for ones with higher education only 25,5 % do it. 69,5 % of the ones with higher education believe in prophylaxis against 29,1% of those with secondary education (c2= 53,364; р=0,000).

Question № 4 Do you pay for visits of specialists?
Due to the lack of directions from GP, willing for a better treatment with better quality and modern medical equipment, looking for more polite attitude and missing the wasted hours in front of the doctor's door in a lot of cases 86 % patients are ready and they pay for a visit in specialists. Amazingly low is the percentage 1,3% of the answers of those who has never ever paid for specialist. 12,7 % are those who rarely pay ( fig №4).

Figure 4: Percentage of answers of question №4
 Age: The highest percentage of ones who pay to visit specialists is for the age of 18-24 years-90,2 %. Followed by 25-44 years old with 86.7%. The lowest percent of the ones who pay is in the group of 60+ years. Most likely it is due to the fact that pensioners have limited financial means. There is a significant difference; (c2= 33,301; р=0,020).  Sex: There is no difference in the answers of both sex.  Education: Ones with high education pay more frequently to visit specialists. There is a significant difference; (c2= 7,808; р=0,020).

Summarized Results
1) The results regarding the trust in GP is very unconvincingonly 14,5 % believe in their GP 2) The percentage of believers in prophylactic check-ups is very high -57,9% 3) The percentage of those who believe in the new methods and means for treatment is high, over 80%, while no difference is found with respect to the patients' education level. 4) The patients often (86%) pay for the treatment. 5) People with higher education more willing to pay for medical care.

Discussion
Personal responsibility for our own health requires increasing the medical education of the society, healthy lifestyle, promotion and prevention of health. Paying for symptomatic treatment shows lack of sustainability in Health care system which means that people are not ready to take responsibilities and are not well educated how to take care of their health. The patients' readiness to pay for a visit of specialists will not compensate the lack health knowledge. A sign of sustainability in Health care system is people's readiness to pay for a prophylactic checkup as a performance of personal choice and responsibility (2,3).
The reasons why patients do not trust their GP are still discussed. One could be the series of reforms in Bulgaria in the Healthcare system. Another could be queue in front of the GP's door and also lack of directions for specialists.
Health promotion puts the health in the center of all politics and directs to personal responsibility for own health and making healthy decisions (6,7,10).
The main role in the promotion of health and prophylactic of diseases take the GP. Their activity could not be adequate if there is lack of trust in them. GP are the ones who have to motivate and educate us to be constant in prophylactic and to let us know the required check-ups for our age. Patient's right is to demand for health information from GP. The high percentage of the believer in prophylactic may be due to the fact that a lot of diseases are diagnosed very late and it is claimed that a lot of them could be diagnosed and treated if the disease is found in the beginning.
The saddest thing is that we learn through the hardest way to pay attention to prophylactic while our relatives or friends are fighting with illness. We should know that it is our own decision how to live our life, how to take care of our own health and body (1,8,9).
Rather disturbing is the data of NFO in Bulgaria that show that only little part of the health insured has visited their GP for the mandatory prophylactic check-ups (12).
Lack of interest to the annual check -up, which may save a life, could be explained with lack or very low level of health care knowledge. Paradoxically no one is paying attention -GP, and patients and they do not carry on their duty (3,4,11).

Conclusions
1) The lack of trust in GP combined with the strong belief in prophylactic check -ups and the new methods for diagnostic and treatment of diseases lead to higher expectations of patients towards the medical services and their readiness to pay for these services.
2) The patients indicate readiness to pay for medical services which is a part of the patients' readiness to take care for their own health.

Recommendations
A systemic change is needed, in order to regain the patients' trust and to encourage their readiness to take personal responsibility for their own health, as well as to improve health promotion.