5. Provision of services
In Bulgaria, health services are provided by a network of various health care providers, in either the private or public sector. Public health services are provided by the state and organized and supervised by the MoH. Various public health programmes are mainly implemented by the Ministry’s local branches, the RHIs, several national centres and by municipalities.
The Health Care Establishment Act (1999) stipulates the distinction between outpatient and inpatient care. The GP is the central figure in primary care and acts as a gatekeeper for specialized ambulatory and hospital care. The number of GPs in Bulgaria has been declining and access to primary care in rural and remote areas is still a challenge. Ambulatory care is also provided by specialized outpatient facilities, including individual and group practices, medical and medico-dental centres, diagnostic-consultative centres and stand-alone medico-diagnostic or medico-technical laboratories. They are autonomous health care establishments, most of them with a contractual relationship with the NHIF. The majority of the outpatient facilities are privately owned. The distribution of specialists across the country is characterized by great regional imbalances.
Inpatient care is delivered mainly through a network of public and private hospitals, divided into multiprofile and specialized ones. There are also other inpatient health care establishments such as comprehensive cancer centres, centres for dermato-venereal diseases, and the newly established centres for comprehensive service for children with disabilities and chronic diseases. Bulgaria has a relatively high hospitalization rate, reflecting the underutilization of ambulatory care services and the lack of integration and coordination of different levels of care.
Long-term care is underdeveloped regarding both community-based services and inpatient care provided by specialized hospitals. For years, both an oversupply of acute care beds and an increasing undersupply of long-term care services have remained.
The centres for emergency medical care (CEMC) with their subsidiaries and hospitals’ emergency wards are the key units in the organization of emergency care. In 2014, the MoH undertook several reforms aiming to improve the infrastructure and material resources; ensure sustainable development of human resources; efficient organization, coordination and management of the emergency medical care system.
Pharmaceutical care in Bulgaria is part of the state health policy and is carried out by the Minister of Health. The Bulgarian pharmaceutical market is one of the smallest in the EU, but it is nevertheless among the fastest growing sectors of the Bulgarian economy.
Dental care is delivered in outpatient and inpatient facilities. The regulations for outpatient dental care facilities are similar to those for primary and specialized medical care. The majority of dental practices are concentrated in the big cities. Only selected dental care services are fully covered by SHI, whereas the majority of procedures are paid for by the patient.
Institutions for residential mental care include specialized psychiatric hospitals, mental health centres, psychiatric wards in multiprofile hospitals, as well as a number of social homes for people with mental disorders. Despite efforts to deinstitutionalize psychiatric patients, Bulgaria still relies on the traditional psychiatric services and outpatient and community-based services are responding insufficiently to the identified needs.
5.1 Public health
Public health in Bulgaria is coordinated by the MoH, as the most competent authority, which is responsible for overall planning, supervision, as well as state sanitary control. Responsibilities are split between the Department of Promotion and Prevention of Diseases and Addictions (mainly dealing with disease control and supervising communicable diseases) and the Department of Health Control (responsible for disease prevention, health promotion and reduction of risk factors for noncommunicable diseases) of the MoH.
The 28 RHIs, which represent the MoH at the district level, are responsible for the coordination and provision of public health services. Their functions include: monitoring health status of the population and health determinants; health promotion and integrated disease prevention; laboratory testing of environmental factors and assessment of their impact on population health; consultation and expertise in the field of public health protection; coordinating the implementation of national public health programmes at the local level; elaboration of public health programmes and projects, control of communicable diseases, sanitary control of public places, products and activities pertinent to human health and environmental factors.
The main bodies of state health control are the Principal State Health Inspector as its supervisor, and the National Centre of Radiobiology and Radiation Protection. The Principal State Health Inspector, appointed by the Prime Minister at the proposal of the Minister of Health, supervises and organizes the state sanitary control, health promotion and disease prevention activities and prophylactic and anti-epidemic activities in case of disasters, accidents and catastrophes. The Inspector is, therefore, the main supervisor of the state health control system. The activities of the Principal State Health Inspector are assisted by the Department of Health Control.
The National Centre of Radiobiology and Radiation Protection is responsible for control of parameters related to the working and living environment; assessment and reduction of public exposure to ionizing sources; dosimeter control of personal external and internal exposure; risk assessments for the population and for particular groups.
The public health network in Bulgaria also includes several national centres, which are engaged in public health protection and promotion and are owned by the MoH. These national institutes provide expertise and advisory assistance to RHIs or health care establishments if needed.
- National Centre of Infectious and Parasitic Diseases – the centre monitors and conducts research on infectious and parasitic diseases and is involved in anti-epidemic control and the prevention of infectious disease outbreaks.
- National Centre of Drug Addictions – the centre coordinates and provides methodological guidance on drug abuse and addiction-related issues, including the prevention, treatment and rehabilitation of persons abusing drugs (with and without addiction), specialized control over their treatment process and the provision of expertise on drug addiction.
- National Centre of Public Health and Analyses (NCPHA) – the centre provides methodological support and expertise in public health protection, as well as consultations to the health administration and to health care establishments; assesses the impact of environmental and other risk factors on health; conceives and implements programmes for health promotion and disease prevention; supervises HTA and the accreditation processes; and carries out scientific research. The Centre is responsible for providing information on health status in the country, socioeconomic determinants of health, and on the health care system, its structures and resources.
Furthermore, control of safety and quality of food is carried out by the Bulgarian Food Safety Agency to the Ministry of Agriculture, Food and Forestry.
The MoH and its subordinate bodies use an intersectoral and multilevel approach in their work, collaborating with other sectors’ institutions at the national and local level, such as the Ministry of Environment and Water and its regional inspectorates, the Ministry of Labour and Social Policy, the Ministry of Education, Youth and Science, the Ministry of Agriculture, Food and Forestry, the State Agency for Child Protection, municipal councils and local administrations, and patient organizations (see section 2.6 Intersectorality).
Key public health programmes in Bulgaria are summarized in Table5.1. They are developed by the MoH and approved by the CoM. The programmes are implemented by different public institutions, municipalities and NGOs. The municipalities also adopt and implement local programmes for health promotion and disease prevention, financed through independent municipality budgets or donor programmes.
Public health services in Bulgaria are provided by the state and financed mainly by the state budget (see section 3.7.1 Paying for health services). In addition, municipalities implement and finance local programmes, while the NHIF pays for some services provided by GPs (such as immunizations and prophylactic check-ups).
In 2015, 2.55% of overall health spending in Bulgaria was allocated to preventive care, which was close to the EU average. In the same year, 0.42% of health care expenditure was spent on immunization programmes – among the highest levels in the EU (Eurostat, 2018).
Communicable diseases and immunization
The RHIs are responsible for the surveillance of communicable diseases in Bulgaria. People with contagious diseases, contact persons and contaminants are subject to registration and mandatory reporting. The Minister of Health determines by ordinance which communicable diseases are subject to notification, registration and reporting based on the 2004 Health Act. Any medical professional who diagnoses a reportable communicable disease must inform the regional inspectorate and the patient’s GP.
Fig5.1 provides an overview of the information flow in surveillance for communicable diseases. The NCPHA compiles information by RHIs, operates a central information system for reporting and monitoring incidences of infectious diseases and prepares weekly and monthly epidemiological bulletins by diagnosis and by districts. Furthermore, the MoH has maintained specialized case-based reporting information systems for HIV/AIDS and for tuberculosis since 2005. The informational systems for measles, rubella and mumps, and for influenza are supervised by RHIs. Epidemic outbreaks and outbreaks of nosocomial infections have to be reported immediately to the MoH and the National Centre of Infectious and Parasitic Diseases. The latter takes part in organization and control of prophylaxis and anti-epidemic activities in the field of infectious diseases in Bulgaria.
The Minister of Health determines by ordinance who (in terms of age groups) is subject to immunizations, as well as the methods and the terms for carrying out either compulsory, targeted or recommended immunizations. The Bulgarian immunization calendar is approved annually and vaccinations and revaccinations are scheduled by age groups. Compulsory immunization provided by GPs free of charge covers vaccination for tuberculosis, hepatitis B, diphtheria, tetanus, pertussis, poliomyelitis, rubella, measles, mumps, Haemophilus influenzae B and pneumococci. Participation in these vaccinations is obligatory for the target population. In the case of non-compliance there are sanctions, for instance parents who refuse to have their children vaccinated cannot use kindergarten and must pay penalties as regulated in the 2004 Health Act. Second, targeted immunization against rabies, Crimean–Congo haemorrhagic fever and abdominal typhus are provided only in certain cases. Vaccines for targeted immunization are paid through the state budget and provided free of charge. Third, recommended immunizations against yellow fever, hepatitis A, rotaviruses, human papillomavirus, influenza, meningococci and pneumococci are possible. Some of the noncompulsory vaccinations recommended by the MoH for certain high-risk populations are free of charge (for example, vaccines against rotavirus and human papillomavirus). Noncompulsory vaccination programmes are delivered through the National Centre of Infectious and Parasitic Diseases, health care establishments and the RHIs. Noncompulsory vaccinations can be requested and paid for by patients.
Since 2012, vaccination rates have been falling (Table5.2). In 2016, vaccination rates for compulsory immunizations were below the target of 95%, with the exception of primary immunization against tuberculosis (National Centre of Infectious and Parasitic Diseases, 2017). The decreasing rates are the result of both a negative perception of compulsory vaccinations among parents and vulnerable groups of individuals, for example the Roma community.
The last outbreak of measles was recorded in 2009–2010, mainly among Roma children. In 2017, there were 36 cases of measles identified among the Roma community living in Plovdiv. In such cases (as well as in emergency epidemic situations or significant declines in immunization coverage), the Minister of Health can order additional compulsory vaccination and revaccination.
Furthermore, targeted human papillomavirus vaccinations exist and aim at girls of 12 or 13 years. In these groups, vaccine uptakes were 14.3% and 5%, respectively, in 2016 (National Centre for Infectious and Parasitic Diseases, 2017). The low uptake was, inter alia, the result of the death of a 14-year-old girl, which was associated in the media with human papillomavirus vaccination.
Health promotion, disease prevention, prophylaxis and screening
The concept “Objectives for Health 2020” (2015) envisages to strengthen public health capacities, including health promotion and disease prevention for communicable and noncommunicable diseases. Primary health care providers and their further development are seen as key for an efficient delivery of these services. According to the concept, “the significant number of already existing national prevention programmes creates duplication of activities, which is an unjustified waste of financial resources” (MoH, 2015b). Thus, priority is given to the National Programme for the Prevention of Chronic Noncommunicable Diseases (2014–2020) as an integrated approach to reducing premature mortality, morbidity and related health consequences.
This approach is further developed in the NHS 2020 (MoH, 2015c). The Strategy envisages interventions to reduce risk factors, expanding the range of hospital services in the field of health promotion and disease prevention, promotion of healthy nutrition, improving the quality of health education and training, coordination and synchronization of sectorial policies and the active involvement of different stakeholders among others (see section 2.5 Planning). The National Programme for Prevention of Chronic Noncommunicable Diseases has implemented a wide range of activities to encourage healthy attitudes and behaviour, such as:
- education and communication campaigns
- offices for consulting about the ban of tobacco products from health care establishments
- sports initiatives
- training for health professionals
- surveys on the risk factors and the level of health literacy in the population.
The last survey was carried out in 2014 by the NCPHA nationally and among the population aged 10–19 and over 20 years. The programme lasts till 2020 and is financed through the state budget with a total amount of BGN 9.5 million (approximately €4.9 million) (MoH, 2014c).
Reducing risk factors
The Health Act includes some measures aiming at the reduction of risk factors.
Tobacco and alcohol
Amendments to the law prohibiting smoking in public places were enacted in 2009. The only exceptions to this law are airports. Broadened restrictions on smoking in public places came into force in 2010, when the Health Act introduced a complete smoking ban on playgrounds and in the surroundings of kindergarten and schools. However, these restrictions have not been strictly respected. The Health Act also prohibits the direct advertising of alcohol; indirect advertising on radio and television is allowed after 22:00. Other measures are the restriction on tobacco advertising, increasing tobacco prices, the introduction of new packages with information and pictures about smoking consequences. Overall, alcohol and tobacco are not sold to persons below 18 years of age. According to the Health Act (2004), 1% of the revenues contributed to the state budget from excises on tobacco and alcohol products are used to fund national programmes to reduce smoking and alcohol abuse and to prevent drug use.
In October 2015, the MoH announced a draft law on a Public Health Tax. Foods and drinks containing salt, sugar, trans fats, caffeine and taurine should be taxed above a predefined quantity. The main goal of the law was to improve population health by nudging dietary habits, limit the production of unhealthy food and save health expenditure in the long term. After a vigorous public debate, the law has not been passed in parliament.
Despite different efforts and programmes in the field of health promotion and education, there are still insufficient results. Risk factors such as smoking, alcohol abuse and unhealthy nutrition are widespread (see section 1.4 Health status). According to the NCPHA, the risks of smoking are underestimated, smoking is generally tolerated, and existing legislation on tobacco control is not respected (NCPHA, 2015a). The national representative survey, conducted in 2014, reveals that knowledge on risk factors and causes of severe diseases is insufficient in Bulgaria (Dimitrova et al., 2015).
Monitoring risk factors in patients and screenings
Prophylactic and dispanserization activities are regulated by ordinance of the MoH (with the latest update in 2016). According to this ordinance, GPs assess risk factors in all patients, guided by updated criteria, and group patients according to their health risk. Additionally, prophylactic examinations and diagnostic tests by type, volume and periodicity for each patient risk group are specified. These are focused on early detection of cardiovascular diseases, type 2 diabetes mellitus, and several malignant neoplasms. Prophylactic activities for children include different diagnostic tests, examinations and immunizations specified by age group. Every insured person over 18 years of age is entitled to one prophylactic check-up per year. The prophylactic examination includes: medical history and complete objective status, laboratory tests of blood and urine, filling in a questionnaire and formation of risk groups. Additionally, since 2011, a prostate-specific antigen prostate cancer test for men over 50 years of age and breast mammography screening for women over 50 years every 2 years have been included. In the case of risk of diabetes, heart attack, stroke, and cardiovascular and malignant diseases, the GP may also refer to a respective specialist. The volume of diagnostic tests and the number of check-ups to dispensary surveillance for chronically ill people depend on their condition and diagnosis. The NHIF pays for the prophylactic and dispanserization activities.
The screening system consists of a National Screening Register and regional coordinators in each RHI. The National Screening Register is run by the NCPHA. Financing of screening can be provided by the different sources: programmes and projects; the state budget; the budget of the NHIF; and donors.
According to a national representative survey, the frequency of the prophylactic check-ups was very low in 2014 (Dimitrova et al., 2015). Around one quarter of the respondents had never checked their cholesterol; over 70% of men had never been screened for prostate cancer and 33% of women had never attended a mammography. In contrast, self-reported screening rates for cardiovascular diseases and diabetes risks (measurement of blood pressure, blood cholesterol and blood sugar) in the last 5 years ranged between 78% and 89% (Eurostat, 2018). In 2016, the average number of prophylactic examinations per infant up to 1 year was 10.0 and the average number of prophylactic visits per insured persons over 18 years by GP was 0.37 (NHIF, 2017b).
Maternal and child health, reproductive health
Maternal and child health is one of the main priorities of public health policy according to the concept “Objectives for Health 2020” and the NHS 2020 (MoH, 2015b, 2015c). Every pregnant woman is eligible for health services from the beginning of pregnancy to the 42nd day after childbirth. Prenatal and postnatal services include promotion and training in nutrition and newborn care, regular check-ups and prenatal diagnosis and prevention of congenital disorders, provided by primary and specialized ambulatory care facilities, as well as hospital services during the delivery. The National Programme for Improvement of Maternal and Child Health (2014–2020) embraces an integrated approach of involved institutions to maternal and child health. Under this programme, centres for maternal and child health have been established at district hospitals. The programme also envisages health promotion and educational activities for pregnant women and parents. The total budget of the programme is BGN 128.6 million or approximately €65.7 million (MoH, 2014b).
There are a number of programmes and initiatives to improve child health in general and to reduce infant mortality in particular. Children up to 18 years of age are entitled to free access to paediatric care and are incentivized for regular medical check-ups, conducted by GPs and paediatricians. Furthermore, medical offices in schools, kindergartens and social institutions for children provide first aid services. Medical professionals working in these offices are also responsible for organizing and conducting health education programmes. In 2015, the Health Care Establishments Act introduced a new type of health care establishment, that is, centre for comprehensive service for children with disabilities and chronic diseases. These centres will provide screenings, prophylaxis, diagnostics, treatments, rehabilitation, long-term care and palliative care to children with disabilities and chronic diseases (see Chapter 6 Principal health reforms).
Reproductive health is safeguarded by the state by means of promotion and consultation, access to specialized medical care, and prevention and treatment of sterility. In the past decade, several centres for reproductive health have been established, some of them as a part of public or private health care establishments and others as independent medical practices or medical centres. Many of these centres also provide assisted reproduction (in vitro fertilization). Since 2009, the MoH created the Assisted Reproduction Fund, which financed up to three in vitro attempts per person. In May 2017, the CoM approved additional financing of assisted reproduction services to lift the ceiling of three attempts (CoM, 2017a). This decision is in line with the policy targeting the demographic situation in Bulgaria (see section 1.1 Geography and sociodemography). In August 2017, the MoH proposed up to eight in vitro procedures per couple. In the period of 2014–2015 a total of 7598 procedures were financed and 2171 children were born (Bulgarian National Audit Office, 2017). Some municipalities also offer programmes for additional funding of in vitro procedures.
Occupational health services and other public health activities
The organization of occupational health services is regulated mainly by the 1997 Law on Health and Safety at Work. The MoH and the Ministry of Labour and Social Policy are jointly responsible for occupational health and injury prevention. Occupational diseases are the responsibility of occupational medicine facilities, which are either independent legal entities or legal entities created by a particular enterprise or health care establishment. The services are chiefly preventive: surveillance of working environment to assess risk; evaluation and monitoring of employees’ health status and working ability; statutory health surveillance by screening of workers exposed to specific hazards; and provision of information to employers and employees, counselling and guidance about health risks and their prevention.
The NCPHA is responsible for the collection, analysis and publication of health statistics and epidemiological data. The system for notification and surveillance of communicable diseases and epidemic outbreaks is efficient and enables timely and adequate measures. However, this is not the case with noncommunicable diseases, for which data are often unreliable, incomplete or not available. There are not regular surveys of health behaviour in Bulgaria. Such surveys are usually conducted in the framework of different projects and programmes.
Despite the various public health programmes and initiatives, results have not been entirely satisfactory in Bulgaria. Nonetheless, challenges remain in ensuring access to quality public health services for the rural population, and for vulnerable and ethnic groups, such as the Roma minority.