Healthcare access inequalities in Central and Eastern Europe: structural and socioeconomic determinants

Access to healthcare is a topic of exceptional social sensitivity, which occupies an important place in scien­tific research, public debate, and policy. In the countries of Central and Eastern Europe (CEE), these issues are of particular importance, while in Western Europe the problems of access to healthcare tend to be less pronounced on a systemic level. However, even within Western European countries, significant disparities persist, particularly along socioeconomic lines and between rural and urban areas. Therefore, inequalities appear at the inter-country and intra-country level. The issue of access to healthcare raises many speculations. The gaps in the public system are often filled by private sector initiatives that implement advanced technologies. These modern solutions, although innovative, often raise new challenges regarding equal access to medical services. Social responses to healthcare changes and the level of access to services are equally important. References to countries with high-income economies (HICs) and internationally recognized healthcare systems provide a useful benchmark for evaluating access standards.
In the CEE region, differences in the availability of healthcare services are significant, manifesting themselves in waiting times, financial burdens, and quality of care. In addition to inter-country differences in the quality of healthcare systems, intra-country differences are also evident, such as differences in access related to income or place of residence, which translates into access to facilities close to home. Inequalities in access to healthcare translate into poorer health, higher mortality rates, lower life expectancy, and inequalities in the treatment of chronic and life-threatening diseases, which are also related to citizens’ lifestyles [1, 2].
This paper aims to present the general condition of healthcare systems in the European Union (EU)countries belonging to CEE, with particular emphasis on the persistent inequalities between member states. The analysis focuses on identifying the key socioeconomic, geographic, and systemic factors that shape disparities in access to healthcare services across the region. The study also seeks to contextualize the CEE region within the broader European framework, offering insights into how historical, economic, and policy differences contribute to uneven progress toward equitable healthcare access.

SOURCES OF HEALTHCARE INEQUALITY

To present potential barriers to healthcare access, it is essential to highlight the possible sources of these inequalities, which vary depending on a country’s economic status and its society. Some of these barriers share a common foundation, while others are specific to particular regions, countries, cultures, or social groups. Academic publications dedicated to this topic point to a number of factors contributing to health inequities. There may be many more, but based on recent research, several key ones stand out.
A major barrier affecting healthcare access inequalities is the cost of services. In low- and middle-income countries (LMICs), high out-of-pocket expenses commonly hinder access to even basic healthcare. This is often due to a combination of limited public healthcare funding, partial coverage of essential services by insurance systems, and the prevalence of informal payments. Patients frequently have to take out loans or sell assets to afford treatment [3]. While these patterns are observed globally in LMICs, they are particularly pronounced in CEE, where healthcare systems face both historical underfunding and ongoing transitional and financial challenges.
These financial challenges are especially crucial in the CEE region, where disposable incomes are lower than in other EU countries and income disparities are relatively high. The differences are stark – the EU median equiva­lised disposable income in 2023 was €20,350, while in Belgium it was €28,997, in Croatia €9,873, in Hungary €7,423, in Romania €6,568, and in Bulgaria €6,523 [4]. In these countries, treatment costs relative to income are higher than in developed economies. Bulgaria, in particular, bears much higher healthcare expenditures compared to other European nations – according to the World Health Organization (WHO) Europe report [5], in 2018-2019, one in five households incurred healthcare costs exceeding their financial capacity by up to 40%, often forcing families to forgo basic needs such as food, housing, electricity, or other utilities. Income-related differences represent a broad category of barriers when comparing LMICs globally with HICs, and similar patterns can be observed within certain CEE countries, regardless of whether they belong to HIC or LMIC groups. Within these CEE countries, disparities also exist between urban and rural populations and across income groups, reflecting internal inequalities beyond the inter-country comparison. In HICs, financial burdens related to insurance and co-payments can also pose significant barriers. These comparisons include both inequalities between countries and within countries, such as differences in income, location, or access to healthcare services. This also applies to comparisons within the EU or between European countries in general [6].
In addition, Dawkins and colleagues, using a systematic review, identified a group of barriers, including delays in accessing medical services, which they divided into three main types: delays in making the decision to seek treatment, reaching the appropriate facility, and receiving the actual service. An important barrier related to access is social stigma (and even self-stigma), influenced by health literacy and culturally conditioned behaviours. Often, the decision not to seek treatment stems from individual choices shaped by socio-cultural and economic factors, such as fear of stigmatization associated with certain types of services like reproductive health, substance use [7], sexually transmitted diseases, HIV [8], or mental health. For example, according to WHO data, 60% of people in Poland in need of mental health support did not seek help due to stigma [9]. It is worth noting, however, that socio-cultural norms, including gender-related expectations, can pose barriers to healthcare access not only in LMICs but also in HICs.
These concerns are linked to variables such as belonging to specific social groups. Such attitudes reflect levels of conservatism, openness, patriarchal systems, socie­tal treatment of women, education, and the scientific approach to healthcare [10]. They also relate to gender roles [11], rooted in socio-cultural norms – especially in LMICs, where the decisions of some groups, such as women, may be limited by lack of financial resources, consent, or autonomy from family, strong hierarchical systems, and limited self-determination [12]. This situation is often gender-based and predominantly affects women.
Health literacy influences perceived needs for diagnosis and treatment not only in LMICs but also in HICs. According to a European Patients’ Forum (EPF) research report [13], 12.3% of women in CEE reported experiencing stigma when accessing healthcare services solely due to being female. Health literacy is therefore an important factor shaping healthcare access in these countries. Additionally, over 53% of survey respondents cited multiple cases of discrimination based on ethnicity, age, social status, or disability. Education level and health awareness, knowledge about health conditions, and availability of treatment also play a crucial role.
Geographic and logistical barriers present further challenges – rural and remote areas often lack adequate healthcare infrastructure, forcing patients to travel long distances at high cost to receive care. While access challenges in rural areas exist worldwide, they are particularly pronounced in CEE countries, due to a combination of historical underinvestment in rural healthcare, high urban centralization of specialized services, and slower development of transportation infrastructure compared to Western Europe [3, 6]. Delays in reaching the appropriate healthcare facility stem from a limited number of suitable medical centres, geographical isolation (especially in rural areas far from specialized units [14, 15]), healthcare centralization in densely populated cities, poor or expensive public transportation, and inadequate road infrastructure. Resource limitations often result in reduced care standards – facilities suffer from shortages of necessary supplies, medications, and qualified personnel. Care quality is further diminished by staff exhaustion and low morale due to difficult working conditions. These factors can lead to dismissive or unprofessional attitudes toward patients, negatively impacting the quality of care and potentially causing errors [5, 16]. The CEE countries face delays in receiving care even once patients reach healthcare facilities, due to long waiting times, insufficient or inadequately trained staff, and administrative obstacles. Overloaded facilities and staff shortages [16] are common, particularly in LMICs, where high patient-to-provider ratios result in extremely long waiting periods. In HICs, although facilities are generally better equipped, healthcare systems also struggle to manage demand during peak times, leading to delays even in well-developed, high-quality services [6, 12]
Nevertheless, even the numerous technological advancements accelerated by the COVID-19 pandemic [17-19] and the rise in healthcare quality and availability have introduced new inequalities, widening the gap between the digitally excluded and those proficient in using modern technology. This issue may deepen in the context of aging populations [20] and the increasing number of chronically ill patients [21, 22].
According to an EPF report [13], these differences are especially visible in EU countries in the CEE region – 51.1% of respondents reported postponing doctor visits due to financial reasons, compared to 34.9% in other EU countries. The differences between rural and urban areas in the CEE region are more pronounced than in Western Europe. Rural areas often lack adequate facilities, specialists, and even basic healthcare, which is unevenly distributed. This is particularly important because the proportion of the population living in rural areas in CEE countries is higher than in the rest of the EU [23].
Waiting times for services remain longer in publicly funded healthcare systems, which are prevalent in post-communist CEE countries, where acknowledged treatment-time inequalities exist – to the advantage of wealthier individuals [24]. These inequalities are not primarily due to hospital choice or the type of treatment related to specific conditions [25]. Analyses show that only a small portion of the general differences in waiting times can be attributed to facility choice [26]. Attempts to reduce income-based waiting time disparities over the past two decades have yielded little impact [27, 28].
In conclusion, the accessibility of healthcare is constrained by a multifaceted interaction of economic, geographic, socio-cultural and systemic factors, which vary both across and within countries. In comparison to HICs, CEE countries are confronted with several challenges, among others related to patient experiences and financial barriers resulting from insurance structures and healthcare shortages. However, these challenges are often more fundamental, including the lack of healthcare facilities and lower income levels with comparable prices for medical treatments. To address these inequities, a comprehensive strategy is necessary, integrating infrastructure development, policy reforms and cultural sensitivity. Such an approach would ensure healthcare access for all individuals, regardless of their socioeconomic background, and align with the Sustainable Development Goals (SDGs). Particularly relevant is SDG 3, which aims to achieve universal health coverage, and ensure a healthy life and well-being for all ages [29]. Achieving access to healthcare is pivotal for both individual health and societal stability.
In summary, systemic and structural sources of healthcare inequality, including the organization of health services, financing mechanisms, and service availability, create barriers at the national and regional levels. These systemic disparities are closely intertwined with individuals’ socioeconomic circumstances, such as income, education, and employment, which in turn shape their ability to access care.

SOCIOECONOMIC AND PERSONAL DETERMINANTS OF HEALTHCARE ACCESS INEQUALITY

While the previous section discussed systemic and structural sources of healthcare disparities, this part focuses on socioeconomic and personal factors that directly influence a person’s ability to obtain timely and adequate healthcare. In the countries of CEE, these challenges are particularly pronounced, as income, education, and employment conditions often determine whether patients can afford treatment and access services and therapy. The unequal distribution of healthcare resources in the CEE is shaped by a complex interplay of socioeconomic factors. These challenges, which are multifaceted in nature, emerge from a combination of financial, systemic, and societal elements that limit the availability of healthcare, with these financial constraints representing a significant challenge for patients, encompassing both direct and indirect costs. In Croatia, for instance, patients frequently report difficulties in affording out-of-pocket expenses, including travel costs, medication not covered by insurance, and diagnostic procedures [30]. Furthermore, indirect costs, such as income loss resulting from long-term inability to work, serve to exacerbate financial status. A significant number of patients face challenges in obtaining part-time employment or accessing sick leave benefits, which can result in increased vulnerability to job loss and economic instability. Despite the apparent provision of free healthcare services by public healthcare systems in the CEE region, socioeconomically disadvantaged populations bear a disproportionate burden of hidden costs, including informal payments and expenses not covered by the system. Such covert expenses deepen inequalities and place an additional strain on financially vulnerable households. Furthermore, the absence of systematic and transparent communication regarding available financial assistance and social support programs serve to increase the difficulty of challenges faced by patients. Consequently, many individuals are compelled to rely on informal channels to obtain critical resources, which often results in limited access to support, with the financial implications of a serious illness frequently extending beyond the individual patient, affecting the wider household and potentially leading to economic distress and vulnerability. It is not uncommon for families to be forced to deplete savings, sell assets, redirect planned spending or incur substantial debt to meet the financial demands of healthcare. This reallocation of resources frequently results in neglecting basic needs, such as housing, nutrition and other essentials, thereby further compromising the household’s overall well-being. What is also visible is that patients from wealthier backgrounds experience shorter waiting times for healthcare compared to their poorer counterparts, with up to a 35% or 43-day difference between the most and least affected groups. While the patient’s choice accounts for up to 12% of this inequality, the residual socioeconomic gradient remains significant even after accounting for the choice, which suggests that external factors such as institutional bias or limitations in healthcare availability contribute to these differences [25].
Delays in access to care also underscore financial barriers: patients in CEE countries who want faster access to medical services often have to pay out of pocket, instead of relying solely on public health insurance systems. In LMICs, direct payments at the point of care are common and often unaffordable, especially for low-income households – which also applies to CEE countries, resulting in, among other issues, high cancer mortality rates. The earlier the disease is diagnosed and the quicker the access to appropriate healthcare, the higher is the chance of survival. This puts Western European countries in a privileged position. The cancer mortality rate is highest in Poland, Hungary, Croatia, Slovakia and Slovenia, with Romania, Estonia and Latvia also above the EU average. On the opposite side of the scale are Finland, Spain, Sweden, Austria and Belgium. The difference between the top 5 and bottom 5 countries is significant [31]. Cancer care, along with related mortality and survival rates, remains a vulnerable area. Geographic disparities in that area further amplify socioeconomic inequities, particularly in CEE countries. Patients residing in economically disadvantaged areas often incur additional non-medical costs for transportation and accommodation when seeking care in distant, dense urban centres, which disproportionately affect low-income households, creating additional barriers to timely and adequate treatment. Furthermore, employment-related challenges intensify the economic pressure that patients are already facing. It is not uncommon for individuals undergoing treatment to encounter unsupportive workplace environments, with prolonged absences due to treatment and recovery often resulting in job termination, which serves to highlight the inadequacy of existing workplace protection for individuals navigating the dual challenges of managing a serious illness and maintaining employment [32]. The cumulative effect of these systemic and structural shortages serves to underscore the urgent need for targeted interventions to alleviate economic burdens faced by cancer patients and their families. For instance, the provision of cancer care in the context of CEE countries serves to deepen the differences in wealth distribution and leads households to poverty, transforming a health crisis into a significant driver of long-term economic instability of entire families. The most vulnerable populations, e.g. elderly people or those who already experience financial difficulties, are disproportionately affected by the financial burden associated with cancer treatments and other related expenses. Geographic and socioeconomic disparities in CEE further amplify inequities, with delayed access to care, financial constraints, and limited availability of specialized services contributing to higher cancer mortality rates. These socioeconomic challenges not only restrict access to quality healthcare but also intensify the psychological and emotional distress of patients, thereby further diminishing their overall well-being [33].
Lower income, financial status and education levels correlate with higher mortality, especially for cancer linked to lifestyle factors, such as smoking. For example, a study on cancer treatment found that lower-educated men with lower income had a 2.4 times higher risk of lung cancer mortality compared to higher-educated men with a higher income. For women, the relative risk was 1.8. [34]. According to the cancer death toll, lung cancer is the primary contributor to disparities in cancer mortality, accounting for a significant proportion of the observed inequality, with figures ranging from 29% to 61% among men and 10% to 56% among women [34], varying depending on the country. Additional cancers that contribute to these disparities include stomach, colorectal and liver cancer, with the magnitude of their impact differing across regions. The most socioeconomically disadvantaged groups demonstrate inferior health outcomes and higher mortality rates, which is reflected in considerable discrepancies in life expectancy between individuals situated at the opposite end of the social hierarchy [35]. In Estonia, for example, the mortality gap between individuals with the highest and lowest levels of education increased significantly during the transitional period following the collapse of Soviet domination in the region. By the year 2000, a 25-year-old male with a higher level of education could expect to live 13 years longer than his counterpart with the lowest level of education [36]. Among European countries, mortality rates are highest in the Baltic and CEE regions [37], whereas Southern European countries typically demonstrate lower levels of inequality in mortality rates. It is notable that the Nordic countries, despite their historically robust social safety nets, are experiencing an increase in socioeconomic disparities in lung cancer mortality among women, which is a growing concern. Although disparities in health outcomes are generally more pronounced among men, the gap for women is increasingly widening, particularly in relation to cancers associated with smoking and alcohol consumption. At the same time, the persistently high mortality rates among men remain a major concern, especially in CEE countries. The mortality rate among men is significantly higher in CEE countries than in other EU member states, with privileged countries such as Finland and Sweden facing a mortality rate 22.9% lower than the EU average, while Croatia, Poland and Estonia exceed it by more than 30% [31].

CHALLENGES AND NEEDS

Effectively addressing these socioeconomic barriers requires the implementation of comprehensive and targeted interventions, and it is necessary to prioritize the design and implementation of appropriately targeted financial support mechanisms with the objective of mitigating both direct and indirect costs associated with healthcare. It is also important to redesign communication strategies in order to guarantee that patients are adequately informed about the resources available to them, their rights, and the procedures they need to follow in order to access financial assistance, social support services and appropriate healthcare. In addition to financial measures, structural reforms within the workplace are of critical importance. Legal frameworks should be established to protect flexible working arrangements and ensure job security for individuals undergoing treatment for serious illnesses. These measures would empower patients to prio­ritize their healthcare needs without compromising their economic stability. Addressing geographic disparities requires strategic investment in healthcare infrastructure and workforce development, particularly in regions facing significant shortages. Such efforts are essential to achieve an equal level of healthcare distribution, and should ensure that all patients, regardless of their location, have access to high-quality care. These interventions may be a step toward reducing disparities and fostering equity within healthcare systems among countries and regions.
The socioeconomic challenges highlight deep inequities in healthcare delivery and accessibility across CEE countries, which leads to the conclusion that there is an urgent need for interventions that address financial, systemic and geographic barriers. By mitigating these challenges, healthcare systems in the region can advance toward more equal, accessible and effective healthcare, ultimately improving patient outcomes and quality of life.
Differences are also visible among non-CEE EU member states (Figure 1). Although some countries are below the EU average, most spend more, reaching the level of USD 6.531 in 2021 in Luxembourg, which is even more visible using relative comparisons taking the EU average as 100% (Figure 2).
The trend of increasing healthcare spending is also evident. However, significant differences remain, as healthcare spending in non-CEE EU states the level is usually close to the EU average (except Greece, Portugal and Spain), while most exceed it by 1.2 to almost 1.6 times, as seen in Luxembourg. The disparities clearly place CEE countries at a disadvantage.
Comparing non-EU CEE countries provides an interesting insight, with the data highlighting the relativity of low spending in CEE EU countries. Though it seems to be significantly lower than in most other EU countries, the amount directed to healthcare in EU CEE countries seems extremely low.
The results (Figures 3 and 4) show that spending in countries such as Moldova or Belarus are lower than the EU average, barely reaching 40%. Armenia (USD 342) or Albania (USD 449) were far below the EU average of USD 3,978.64 in 2021.
The difference between these countries and the EU remains high, although some reach a relative level of healthcare spending close to CEE countries, with ca. 40% of the EU average (Figure 4).
Furthermore, issues of approachability and acceptability present considerable obstacles. Inadequate communication between healthcare providers and patients [29], together with limited transparency regarding available services, decreases trust levels in the healthcare system and discourages the use of professional healthcare. Low health literacy among marginalized populations intensifies these challenges, with cultural and social factors, such as discrimination, even deepening the problem. Patients facing discrimination often encounter denial of services, verbal abuse, or treatment that is below the expected standard. These practices not only stigmatize the affected populations, but also deter them from seeking necessary and proper quality care.

CONCLUSIONS

The issues related to the accessibility, acceptability, and quality of healthcare in CEE countries are multiface­ted and result from a combination of economic, social, and cultural factors. Inequalities in access to healthcare, both geographical and financial, have serious consequences for public health, leading to deepening disparities in quality of life and life expectancy, especially among the poorest groups. Serious gaps in the availability of appropriate medical services exist in both lower-income and higher-income countries. Often, this is due to the lack of adequate resources in public healthcare systems, such as insufficient numbers of healthcare workers, inadequate infrastructure, and high treatment costs, which force patients to incur additional expenses. In particular, people from lower social classes face greater difficulties in accessing healthcare, further exacerbating health inequalities.
Disparities in access to healthcare are also linked to issues related to discrimination, prejudice, and a lack of effective communication between patients and healthcare professionals. Low health literacy, particularly among stigmatized groups, hinders making appropriate health decisions, and the experience of discrimination can discourage seeking medical help, worsening the health situation for these individuals.
To effectively address these issues, comprehensive actions are necessary, including both structural reforms and changes in the approach to healthcare. Investment in the development of medical infrastructure, particularly in less developed regions, is essential, as is the creation of transparent financial support mechanisms for patients. It is equally important to ensure appropriate working conditions for healthcare workers and to amend labour laws so that individuals suffering from serious illnesses do not have to choose between treatment and employment.
If these actions are implemented effectively, they could contribute to improving the quality of healthcare in the CEE region, reducing existing inequalities, and increasing access to medical services for all citizens, regardless of their socio-economic status. This, in turn, would contribute to improved public health and quality of life, reducing disparities and promoting health equity. The sources of inequalities in access to healthcare presented with the division into rich and poor countries are included in the table constituting Appendix 1.

Disclosure

The authors report no conflict of interest.

References