Bulgaria: health system summary

2022 Health system summary Bulgaria AUTHORS Antoniya Dimova, Maria Rohova, Stefka Koeva, Elka Atanasova, Lubomira Koeva-Dimitrova, Todorka Kostadinova, Anne Spranger, Katherine Polin Anna Maresso (Series Editor) This Health System Summary is based on the Bulgaria: Health System Review (HiT) published in 2018 and relevant reform updates highlighted by the Health Systems and Policies Monitor (HSPM) (www.hspm.org). For this edition, key data have been updated to those available in July 2022 to keep information as current as possible. Health System Summaries use a concise format to communicate central features of country health systems and analyse available evidence on the organization, financing and delivery of health care. They also provide insights into key reforms and the varied challenges testing the performance of the health system. Main source: Dimova A, Rohova M, Koeva S, Atanasova E, Koeva-Dimitrova L, Kostadinova T, Spranger A. Bulgaria: Health system review. Health Systems in Transition, 20(4): 1–256. Please cite this publication as: Dimova A, Rohova M, Koeva S, Atanasova E, Koeva-Dimitrova L, Kostadinova T, Spranger A, Polin K (2022), Bulgaria: Health System Summary, 2022. WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, Copenhagen. ISBN 9789289059299 (PDF) CONTENTS How is the health system organized? . . . . . . . . . . . . . . . . . . 3 How much is spent on health services? . . . . . . . . . . . . . . . . 4 What resources are available for the health system? . . . . 8 How are health services delivered? . . . . . . . . . . . . . . . . . . 10 What reforms are being pursued?. . . . . . . . . . . . . . . . . . . . 12 How is the health system performing? . . . . . . . . . . . . . . . . 14 Summing up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 HEALTH SYSTEM SUMMARY: 2022 3 How is the health system organized? ORGANIZATION Bulgaria’s health system is highly centralized and based on a compulsory social health insurance (SHI) scheme. The National Health Insurance Fund (NHIF), which has 28 regional branches (regional health insurance fund; RHIF), is the sole purchaser of services. Voluntary health insurance (VHI) plays a very small role. The National Assembly approves relevant budg- ets and the National Health Strategy, adopts further health-related policies, and elects the director of the NHIF. While the Council of Ministers (CoM) steers national health policy, the Ministry of Health (MoH) is responsible for governance and functioning of the system. District health policy is organ- ized and implemented by regional health inspectorates (RHIs), local bodies of the MoH, and municipal health commissions. Municipalities are owners of a considerable share of health care providers. Four national professional organizations represent the rights and interests of their members. PLANNING The MoH is responsible for strategic planning in the health system. It defines priorities within the National Health Strategy, with the current one valid through to 2020. The MoH also plans and ensures human resources, the development of medical science, and is responsible for the collection and management of data on population health and the health system for planning and policy. The CoM coordinates the implementation of the National Health Strategy across various agencies, guided by the MoH’s implementation action plan. A National Health Strategy 2030 was approved by the CoM in August 2022 during the last days of the elected government and parliament; new parliamentary elections in October 2022 will determine its future (Republic of Bulgaria, MoH, 2022). The MoH also manages capital investment allocations to state health care providers and the system generally. Municipalities (and private proprietors) are free to invest in their own health care establishments. Subsidies are provided for the acquisition of long-term tangible assets, renovations, and information technologies and systems in state and municipal health care establishments. Ownership of inpatient and specialized outpatient care is mixed, while all primary medical and dental care is private BOX 1 | CAPACITY FOR POLICY DEVELOPMENT AND IMPLEMENTATION The highly centralized governance of the Bulgarian health system provides limited options for priority- setting, planning, organization of service provision, and performance assessment at the regional and local levels. Despite intentions, no significant health reforms have been implemented since the mid-2000s (see Box 5). On the one hand, reform initiatives, coinciding with a fragile political situation, have been resisted by stakeholders. On the other, promising legislation, addressing the most pressing problems of the health system, have been struck down in courts before some of them could enter into force. In an important step to improve the policy process, the Partnership for Health was established in 2015 as a consultative body to the CoM for coordination and partnership in the development and implementation of health policies. The Partnership’s activity has slowed down, however, since 2017. The policy development process is supported by the CoM web portal for public consultations, where strategic documents and legislative acts are available for discussion. BULGARIA4 PROVIDERS Health care providers are autonomous self-govern- ing organizations. Primary medical and dental care, pharmaceuticals, most specialized outpatient care and some hospital care are provided by the private sector. For example, all general practitioners (GPs) own their practices. The state owns some university hospitals and national health centres, specialized hospitals at national level, centres for emergency medical care, psychiatric hospi- tals, centres for transfusion haematology and dialysis, and a share of the district hospitals. Municipalities have ownership of a large share of providers, mostly specialized outpatient care, but also some multi-profile and specialized hospitals. How much is spent on health services? FUNDING MECHANISMS Public sources of health financing in Bulgaria come from SHI contributions and taxes. Private sources include out-of-pocket (OOP) payments, VHI pre- miums, corporate payments and donations. Foreign health assistance, for which EU programmes are the main source, support structural reform and human resources development. Additionally, informal payments are estimated to comprise a large share of household spending on health. The MoH’s budget comprises unearmarked revenue from the central budget and additional revenue of RHIs and national agencies. Municipalities receive funding from the central budget and use local taxes to finance health services. The NHIF budget is financed by SHI contributions and earmarked funds from the MoH. Funds are distributed to the 28 RHIFs, based on population information, historical allocations, and estimates of future health needs. HEALTH EXPENDITURE As a share of gross domestic product (GDP), Bulgaria’s health spending has grown since 2000. However, at 7.1% of GDP in 2019 (Fig. 1), levels remain lower than the World Health Organization (WHO) European regional average (7.6%). Nevertheless, except for Slovenia, Hungary and Czechia, Bulgaria spent more on health as a percentage of GDP than other new EU Member States. Despite similarly per- sistent growth, per capita spending is the lowest in the European Union (EU) at US$ PPP 1798 in 2019 (Fig. 2). In 2019, public sources accounted for 60.6% of current health expenditure (CHE), far below the EU regional average (79.7%). In contrast, private health expenditure reached almost double that of the EU average (39.4% versus 20.3% of CHE), driven overwhelmingly by OOP spending. As mentioned, VHI accounts for a minimal share of health financing. Although increasing, health spending remains low and out-of-pocket payments represent the highest share in the European Union HEALTH SYSTEM SUMMARY: 2022 5 FIG. 1 TRENDS IN HEALTH EXPENDITURE, 2000–2019 (SELECTED YEARS) Note: PPP = purchasing power parity Source: WHO Global Health Expenditure Database, 2022 FIG. 2 CURRENT HEALTH EXPENDITURE (US$ PPP) PER CAPITA IN WHO EUROPEAN REGION COUNTRIES, 2019 Notes: CHE: current health expenditure; EEA: European Economic Area; EU: European Union; PPP: purchasing power parity; UK: United Kingdom. Data for Albania is from 2018. Source: WHO Global Expenditure Database, 2022. US $ P PP % G DP Current health expenditure per capita Current health expenditure as % of GDP 2000 2005 2010 2015 2016 2017 2018 2019 0 500 1 000 1 500 2 000 0 1 2 3 4 5 6 7 8 0 2 000 4 000 6 000 8 000 10 000 Tajikistan Kyrgyzstan Uzbekistan Azerbaijan Albania Kazakhstan Republic of Moldova Ukraine Georgia Turkmenistan Turkey Belarus North Macedonia Bosnia and Herzegovina Armenia Serbia Russian Federation Montenegro Monaco WHO Euro average Israel Andorra San Marino Bulgaria Romania Latvia Hungary Croatia Poland Slovakia Greece Estonia Lithuania Cyprus Czechia Portugal Slovenia Spain Italy Malta EU/EEA/UK average Finland United Kingdom France Iceland Belgium Ireland Denmark Austria Sweden Netherlands Germany Luxembourg Norway Switzerland CHE in US$ PPP per capita BULGARIA6 OUT-OF-POCKET PAYMENTS In 2019, OOP spending in Bulgaria was the highest in the EU at 37.8 % of CHE, about 2.5 times the EU average (15.4%). This is the result of cost-sharing for most services covered by the SHI benefits package and direct payments for services and medicines. Although some medicines for chronic disease treatment are paid fully or partially by the NHIF, pharmaceuticals accounted for two thirds of all OOP spending in 2019 (Fig. 3), with negative ramifications for access. Direct payments occur in three cases: for services/ goods not included in the basic package at prices set by individual providers, for services/goods that are included but where patients go outside the standard public patient pathway, and for uninsured individuals. FIG. 3 COMPOSITION OF OUT-OF-POCKET PAYMENTS, 2019 Note: OOP: out-of-pocket; VHI: voluntary health insurance. Sources: OECD Health Statistics; Eurostat Database, 2021 (data refer to 2019). Inpatient 10.4% VHI 1.6% Outpatient medical care 13.1% Pharmaceuticals 66.5% Dental care 5.2% Others 4.8% Government/ compulsory schemes 60.6% OOP 37.8% OOP distribution BOX 2 | WHAT ARE THE KEY GAPS IN COVERAGE? A substantial proportion of the population is uninsured and pays OOP for medical services, unless accessing free emergency health care. The uninsured are mainly citizens living abroad, long-term unemployed people, individuals who choose not to pay into the SHI system, and those without a valid identity card. This latter condition is a requirement for SHI registration and particularly affects the Roma population, homeless, and undocumented migrants. The National Strategy for People with Disabilities 2021–2030 and the National Strategy for Roma Integration 2020 include measures to address these gaps. User fees and cost-sharing apply for most services and goods in the basic benefits package, including dental care, outpatient visits, laboratory tests, and hospital stays. Some services are not covered at all (e.g., occupational health care, elective cosmetic surgery, elective termination of pregnancy, and contraception), while others (e.g., emergency care, inpatient mental health care, transfusion haematology, in vitro fertilization and transplantations, and public health services) are fully covered by the state budget. HEALTH SYSTEM SUMMARY: 2022 7 COVERAGE According to law, all Bulgarian citizens, permanent residents, and individuals with humanitarian status are compulsorily insured. The state pays contributions for pensioners, children and students, and unemployed individuals who are entitled to compensation. Despite these provisions, an estimated 14.8% of the population (over 1 million people) was uninsured in 2019 (estimates based on NHIF data). The number of insured according to the Ministry of Finance is smaller (OECD/European Observatory on Health Systems and Policies, 2021). The statutory benefits package covers a range of primary, secondary, and tertiary level health services and goods, though user fees are prevalent. Certain services/goods are fully financed by the state budget (Box 2). PAYING PROVIDERS In the statutory network, GPs’ income comes from monthly NHIF payments from capitation, payments from the Dispensary Programme, funding for prophy- lactic examinations for adults, and the Child Health Care Programme. Self-employed outpatient specialists and dentists are paid fee-for-service. Those on contract in public or private medical or dental centres work on salary and receive a bonus related to the volume of work. Additional revenue for GPs and outpatient specialists comes from user fees and direct payments. Payment mechanisms in inpatient care differ by institution type and ownership status. Physicians in public hospitals are mostly salaried, with additional performance-related bonuses; other health workers are also salaried. In private hospitals, payment mechanisms are negotiated between employer and all employee cat- egories; performance-related bonuses may apply. Many specialists divide their work time between private outpatient practice and public inpatient health care facilities. FIG. 4 | PROVIDER PAYMENT MECHANISMS IN BULGARIA GPs Specialists Acute Hospitals Hospital Outpatient services Dentists Pharmacies Capitation, user fees, and fee- for-service for specific services and those within designated programmes (child health, maternal health) Fee-for-service Case-based payments based on clinical pathways, clinical and ambulatory procedures; user fees; fee-for- service for those not covered by NHIF Case-based payments based on ambulatory procedures Fee-for-service and user fees Mostly direct payments BULGARIA8 What resources are available for the health system? HEALTH PROFESSIONALS Bulgaria has 428 physicians per 100 000 population in 2020, which is above the EU average (398; Fig. 5). This number has been growing since 1990 due to the concomitant rise in absolute numbers of physicians and population decline. Despite high levels overall, some specialities experience shortages, such as GPs, commu- nicable disease physicians and allergists. Meanwhile, with 421 nurses per 100 000 population, Bulgaria has the second-lowest density of nurses for the EU (regional average: 835; Fig. 5). A low number of nursing graduates and dissatisfaction with salaries and working conditions make it hard to attract and retain nurses. In 2019, after protests for better pay and improved working conditions, increased minimum starting sala- ries for nurses working in state hospitals were negotiated nationally. Emigration, ageing and uneven regional distribution are key challenges for the entire Bulgarian health work- force, particularly in primary care (see Box 3). FIG 5 PRACTICING NURSES AND PHYSICIANS PER 100 000 POPULATION, 2021 OR LATEST AVAILABLE YEAR Source: Eurostat, 2022. The hospital sector in Bulgaria is characterized by overcapacity and, despite high physician density, uneven regional distribution and a shortage of GPs and nurses pose workforce challenges across the system Bulgaria 200 300 400 500 600 700250 350 450 550 650 600 400 200 800 1 400 1 200 1 000 1 600 1 800 2 000 Nurses high Doctors low Nurses high Doctors high Nurses low Doctors low Nurses low Doctors high EU27 N ur se s pe r 10 0 00 0 po pu la tio n Doctors per 100 000 HEALTH SYSTEM SUMMARY: 2022 9 HEALTH INFRASTRUCTURE In 2021, there were 319 hospitals, of which 115 were private (up from 88 in 2010), and 2133 outpatient health facilities (up from 2029 in 2016). The number of inpa- tient LTC and psychiatric facilities has remained stable since 2011 (Republic of Bulgaria, National Statistical Office, 2021). Bulgaria’s hospital system had 641 acute hospital beds per 100 000 population in 2019, the highest in the EU (average: 387). The average bed occupancy rate dropped from 67% in 2016 to 56.1% in 2021, suggesting spare capacity in the inpatient sector as well as possible changes in bed numbers and resources due to COVID-19. Indeed, according to national data, the number of acute hospital beds per 100 000 population increased between 2019 and 2021, from 587 to 617 (or 83% of all hospital beds).* The number of magnetic resonance imaging (MRI) units is below the 1.64 EU average at 1.15 per 100 000 population, but access to computed tomography (CT) scanners is higher (4.05 versus 2.0 per 100 000 popu- lation (Fig. 7). * These numbers do not include the acute beds operated by other ministries (for example, five military multi-profile hospitals) and may contribute to discrepancies in national and international data. FIG. 6 BEDS IN ACUTE HOSPITALS PER 100 000 POPULATION IN BULGARIA AND SELECTED COUNTRIES, 2000–2019 Source: Eurostat, 2022. FIG. 7 HOSPITALS, MAGNETIC RESONANCE IMAGING (MRI) AND COMPUTED TOMOGRAPHY (CT) SCANNERS IN BULGARIA, 2020 Number of hospitals MRI scanners per 100 000 population CT scanners per 100 000 population 319 1.15 4.05 200 300 400 500 600 700 800 EU27 Slovenia Hungary Croatia Denmark Bulgaria 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 Be ds p er 1 00 0 00 in ha bi ta nt s Notes: Hospital data from national sources, 2021. Source: Eurostat, 2022. BULGARIA10 DISTRIBUTION OF HEALTH RESOURCES Districts with medical universities and university hos- pitals have the most physicians and other health pro- fessionals per 1000 population, causing inequitable access to health services, especially in rural areas. In 2021, the average number of insured persons per GP ranged from 1214 in the Pleven district to 3097 in the Kardzhali district, despite these locations having simi- lar population densities, because Pleven has a medical university. There is also considerable regional variation across inpatient establishments and beds. In 2021, the south-western region (SW), where the capital city, Sofia, is located, had approximately one third of all hos- pitals (98 of 319). Although SW has 30% of Bulgaria’s population, the high concentration of hospitals is not based on demographic indicators, but rather on eco- nomic development. Some districts with a comparable population have far fewer hospitals. How are health services delivered? PRIMARY AND AMBULATORY CARE Patients can freely choose their primary and specialist health care providers. GPs are independent, privately operating practitioners contracted by the NHIF, and are registered as individual or group practices, who may employ a nurse or other allied professionals. They serve as gatekeepers, providing referrals to diagnostic testing and most outpatient specialized care. Children and pregnant women have direct access to paediatricians and gynaecologists, respectively. Outpatient specialist care is delivered mainly by a network of private practices (individual or group practices specializing in one area), centres for diagno- sis and treatment, and diagnostic laboratories. However, specialized outpatient services are also provided by multi-professional medical and medico-dental centres, diagnostic-consultative centres (owned and regulated by municipalities), laboratory and imaging facilities, and by centres for dermato-venereal diseases, comprehensive cancer centres, mental health centres, and centres providing comprehensive services for children with disabilities and chronic diseases. GPs are gate keepers, but referral quotas lead to patients circumventing primary care, while efforts to strengthen community-based and integrated care are slow to take effect BOX 3 | WHAT ARE THE KEY STRENGTHS AND WEAKNESSES OF PRIMARY CARE? The population in Bulgaria has free provider choice and may change GPs twice annually. GPs act as gate- keepers, helping to reduce over-consumption. Other strengths include primary level access to pediatricians and gynecologists for children and pregnant women, and a wide scope of primary care services and med- icines offered by the statutory benefits package, including prophylactic and chronic disease monitoring paid on an FFS basis. Despite these features, Bulgaria’s care delivery model remains hospital-centric. Primary care is under- developed and under-resourced, characterized by a limited profile of activities, lack of incentives for teamwork, limited recognition, weak connection with secondary care and inadequate funding. Moreover, the quarterly referral quotas imposed on GPs hamper access to specialized outpatient care and undermine the ability of GPs to fulfil a real gatekeeping and coordination role. Access to primary care is also an issue. GPs and nurses are in short supply across Bulgaria, where work- ing conditions and salaries are inadequate, and poor infrastructure and geographical distances mean that remote, rural areas are especially affected. Recent efforts to strengthen primary care include increased prices of GP services and higher payments for GPs who provide prophylaxis. However, no official, publicly available data exists on the quality of primary care to systematize improvements. HEALTH SYSTEM SUMMARY: 2022 11 To control the volume of services, quarterly quotas are issued limiting the number of referrals physicians can write. Quotas are determined by the responsible RHIF, according to patient lists and previous performance. When quotas are reached, patients must wait, or they can choose to circumvent GPs and go directly to hospital emergency departments or pay out of pocket to access services without referral (around one third of patients in Bulgaria; Box 3). HOSPITAL CARE Patients have free choice of hospitals (public or private). Public hospitals are owned by the state and municipali- ties. The state owns approximately 20% of all hospitals, while more than 40% are municipal. For some, ownership is shared. Hospitals are multi-profile (with at least two specialized wards) or specialized (usually gynaecologi- cal, surgical, orthopaedic, ophthalmological, paediatric or psychiatric). There is a big multi-profile hospital in each district owned by the state and the municipalities in the district, which provides a wide range of medical specialties, has 24-hour emergency wards, and clinical pathology. Some hospitals have a statute of university hospitals granted by the CoM. There are also private, for-profit multi-profile and specialized hospitals. PHARMACEUTICAL CARE Bulgaria spent 34% of CHE on pharmaceuticals (pre- scribed and over the counter (OTC)) in 2019, among the highest levels in the EU (average: 13.9%). The positive list of pharmaceuticals dispensed by physi- cians is determined by the MoH. Some are fully paid by the NHIF, but patients must make a co-payment for others. National health accounts data indicate that OOP payments accounted for 70% of all spending on outpatient medicines (Dimova and García-Ramírez, 2022). Retail sale of prescription-only medicines occurs exclusively in pharmacies; OTC products are available at pharmacies and drugstores. In 2022, there were more than 900 drugstores and 3072 pharmacies (2255 of which were under contract with the NHIF). In 2015, Bulgaria had the third highest density of pharmacies per capita in Europe, after Greece and Cyprus. Most pharmacies are owned by independent entrepreneurs, though hospitals and other health care establishments may operate pharmacies for their own needs. BOX 4 | ARE EFFORTS TO IMPROVE INTEGRATION OF CARE WORKING? Historically, since the 1950s, integrated health care was applied through a well-developed system of dispen- saries aimed at comprehensive care for people with oncological, dermato-venereal, mental and pulmonary diseases. Dispensaries were health care establishments, which provided diagnostic, therapeutic outpatient and inpatient services, follow-up procedures up to rehabilitation care to people with certain chronic dis- eases, and maintained patient registers. In 2010, these dispensaries were transformed into comprehensive centres designed to provide integrated care to patients with specific health needs (e.g., related to cancer, mental health care, and dermato-venereal diseases) Despite efforts, health care structures and processes in Bulgaria lack proper coordination both between health care levels and between health and social institutions, including health promotion, disease prevention, health care management and rehabilitation (Republic of Bulgaria, 2015). In 2015, progress was made when integrated care was first named in legislation. Subsequent changes to the Health Care Establishments Act have so far led to the creation of 10 new centres designed to provide comprehensive services for children with disabilities and chronic diseases, and thus to new integrated health and social services. BULGARIA12 MENTAL HEALTH CARE Inpatient mental health care is provided by special- ized state-owned psychiatric hospitals and psychiatric wards in multi-profile hospitals. GPs, individual or group psychiatric practices, and psychiatrists in diag- nostic-consultative centres and medical centres provide outpatient care. Mental health centres also provide outpatient and inpatient care, preventive treatment, and some social services. The Ministry of Labour and Social Policy with the municipalities manage psychosocial rehabilitation and material and social support in com- munities. Since the late 1990s, NGOs offer treatment for drug addiction. Despite this spectrum of services, Bulgaria relies on traditional inpatient psychiatric services and does not provide adequate community-oriented, psychosocial support to meet population needs. Other issues include a concentration of services in district centres and insuf- ficient continuity and coordination of care. DENTAL CARE Dental care is delivered mainly by outpatient facili- ties. Types of outpatient dental care facilities include individual or group practices for primary dental care and for specialized dental care, medico-dental and dental centres, and dental-diagnostic and orthodontist laboratories. Medico-dental centres have at least three physicians and/or dentists with different specialties and dental centres have at least three dentists with different specialties. Inpatient dental treatment is provided by specialized surgery wards in hospitals. Bulgaria has a high dentist to population ratio, with the number of dentists rising due to the development of the private sector and high co-payments. As with most care, there is a concentration of dentists in urban areas. For special categories of insured, including children under the guardianship of the state, children up to 18 years with mental disorders, and prisoners, services are fully covered by the NHIF. Otherwise, dental services are only partly reimbursed, with patients paying the remainder out-of-pocket. What reforms are being pursued? Many health reform efforts to address systemic chal- lenges in the Bulgarian health system, such as system effectiveness and efficiency, financial sustainability, pop- ulation coverage, and gaps in equity and access, have met with resistance. One initiative to improve efficiency, however, has been implemented: Health Technology Assessment (HTA) was successfully introduced in 2015 and has since been obligatory for all new medicines on the positive drug list. Bulgaria has also introduced changes to financial management to strengthen control over public spending and for cost containment. These include regulations to state hospital financial management, pharmaceutical prices regulation, and the introduction of hospital admissions ceilings. Additionally, purchasing reforms have been intro- duced, including a 2016 reform to minimize informal payments. Periodically, there are also changes to the SHI benefits package, such as the inclusion of new services or revision of volume and prices of services and co-payments. Regarding care delivery, some inpatient services were transferred to ambulatory settings in hospitals or outpatient care providers in 2016. Meanwhile, disease prevention and care integration have long been on the health agenda (see Box 4). Like elsewhere, COVID-19 has been a catalyst for change in the Bulgaria health care system. For example, a centralized system for governance and HTA is a major area of reform, while changes to working arrangements aim to increase attractiveness to certain professions and improve system response to population needs HEALTH SYSTEM SUMMARY: 2022 13 communication on COVID-19 was established in 2020 and COVID-19 testing and treatment was included in the benefits package, which was again further expanded in2022. E-referrals and e-pre- scriptions were introduced in 2021. The pandemic also highlighted and exacerbated shortages in the Bulgarian health workforce, which were addressed by two reforms in 2020. First, the working and financial arrangements for recent physician graduates in certain specialities were changed to attract and retain work- force to these areas. Second, stand-alone nursing and midwifery practices were formally allowed to attract more people to these professions and to respond to people’s health needs (Box 5). BOX 5 | KEY HEALTH SYSTEM REFORMS OVER THE LAST 10 YEARS • HTA governance (2015, 2019, 2021): HTA was introduced in 2015 for the inclusion of new medicines (with new International Nonproprietary Names (INN)) on the positive drug list. Initially under a spe- cial committee at the National Centre of Public Health and Analysis (NCPHA), HTA governance was transferred to the National Council of Price and Reimbursement of Medicinal Products in 2019. In 2021, changes in the terms and conditions for compiling a list of medical devices and determining their reimbursement value were made. • Regulation of informal payments (2016): amendments to the ordinance on access to medical care were introduced to address informal payments. • Shift from inpatient to ambulatory settings (2016): some clinical pathways that require a hospital stay were shifted to ambulatory settings. • Financial management of state hospitals reform (2018): a new standard for the financial management of state hospitals was introduced. • National Programme on Vaccination against Influenza 2019–2022 (2019): the strategy aims to increase flu vaccination coverage for people over 65 through free vaccines and vaccine awareness to 25% by 2022. • Liberalisation of medical specialization conditions (2020): medical specialization graduates financed by the state have more flexibility when choosing employment after graduation. • Amendments to Health Care Establishments Act (2020): changes to legislation permit physicians’ assistants, nurses, midwives, or rehabilitation therapists, with the required experience, to practice independently (and in groups) and perform certain nursing care, health promotion services and dis- eases prevention activities, including at patients’ homes. • National Strategy for Mental Health of the Citizens of the Republic of Bulgaria 2021–2030 (2021) and the National Council on Mental Health to the CoM (2022): the strategy envisions a network of commu- nity-based, comprehensive services to treat severe mental illness and centres for treatment of eating disorders. Other foci include: child-adolescent psychiatry, psychiatry in old age, forensic psychiatry, mental health professionals’ development, and quality of mental health care. The Council oversees the implementation and monitoring of the strategy. • National Health Information System (HIS; 2020–2022): sequential introduction of elements of an integrated information system, including e-referral for inpatient and outpatient care, e-prescription, electronic patient records, registers for vaccinations, and a COVID-19 green certificate. BULGARIA14 How is the health system performing? HEALTH SYSTEM PERFORMANCE MONITORING AND INFORMATION SYSTEMS E-health has been on the policy agenda since 2006, with plans to establish integrated information system. As recent as 2018, HIS in Bulgaria was still characterized by frag- mented information systems with little interoperability. Providers operate separate information technologies and databases, exchanging data with the NHIF and NCPHA, which then consolidate information at the national level. In 2017, a National Health Information System (NHIS), funded by the EU, was announced and endorsed by the NHS 2020 and Bulgaria’s e-government strategy (2014–2020). An e-referral and e-prescription system were introduced in 2021 (see Box 5). Bulgaria does not have a quality management system built on reliable indicators and monitoring mechanisms. Previous attempts to introduce quality and patient safety indicators have not been successful. Additionally, there is no medical error reporting system. Analysis of health care quality is based solely on vaccination rates, rates of preventable and amenable mortality and select hospital admissions. ACCESSIBILITY AND FINANCIAL PROTECTION Despite SHI, almost 15% of the population in Bulgaria was uninsured in 2019. Further, the uneven distribu- tion of physical and human resources challenges access to care, particularly in remote rural areas and smaller towns (see Boxes 2 & 3). Additionally, lack of financial protection pushes poor households towards or further into poverty: OOP spending accounted for 4.4% of final household consumption in 2019 (EU’s highest levels), driven by high cost-sharing and direct payments. A large share comes from the uninsured who must pay directly for medical services and from patients who run up against the quarterly referral quotas imposed on GPs and outpatient specialists and must pay OOP for services or forgo care for some time. Consequently, approximately 19% of households in Bulgaria in 2018 experienced catastrophic spending due to medical expenses, with two thirds concentrated among the poorest households. This is the highest in the EU at nearly three times the regional average (WHO Regional Office for Europe, 2021). Before COVID-19, self-reported unmet needs for a medical examination due to cost, distance, and waiting times dropped considerably, from 10.3% in 2009 (highest in the EU) to 1.4% in 2020 (EU average: 1.8%), albeit with significant differences across income groups (Fig. 8). As elsewhere, unmet needs increased in the pandemic’s first 12 months, to nearly 25% compared with 21% for the EU (Eurofound, 2021). HEALTH CARE QUALITY Quality and quality assurance encounter numerous chal- lenges in the Bulgarian health system, with significant regional differences and multiple factors that hamper patient safety, negatively impacting patient satisfaction (see Box 6). While Bulgaria’s health system is excessively centred on hospital care, primary and secondary outpatient care lack resources. In 2019, the hospital discharge rate was double the EU average (34 464 per 100 000 population), with many hospital admissions related to the treatment of conditions that could have been managed effectively in well-outfitted outpatient care facilities. For example, Bulgaria consistently has the highest hospital admission rates for heart failure in the EU, with 1331 per 100 000 population as compared to the EU average of 333 in 2019) (Fig. 9), and these rates are increasing over time. Regarding the quality of public health interventions, data on preventable mortality suggests significant room for improvement (Box 7). There are several challenges to access and financial protection, and health care outcomes highlight relatively low effectiveness of care HEALTH SYSTEM SUMMARY: 2022 15 FIG. 8 UNMET NEEDS FOR MEDICAL EXAMINATION (DUE TO COST, WAITING TIME, OR TRAVEL DISTANCE), BY INCOME QUINTILE, EU/EEA COUNTRIES, 2020 Note: EEA: European Economic Area; EU: European Union. Data refer to 2020 except for Italy (2019), Iceland (2018) and United Kingdom (2018). Source: Eurostat (2021), based on EU-SILC. 0 5 10 15 20 Malta Austria Luxembourg Germany Netherlands Cyprus Spain Czechia Switzerland Hungary Norway Bulgaria Sweden Croatia Belgium Portugal Lithuania Denmark Italy EU27 Poland Ireland France Slovenia Slovakia Iceland United Kingdom Romania Latvia Finland Greece Estonia Fifth quintile First quintile Total % of population BOX 6 | WHAT DO PATIENTS THINK OF THE CARE THEY RECEIVE? There are no routinely conducted national surveys on public perception of the health system in Bulgaria. In 2018, the MoH initiated a national poll on the health insurance model (Republic of Bulgaria, MoH, 2018). The results indicated widespread discontent with the current model and health care system in general, prompted by the low quality of care, difficult access, and high OOP spending. According to respondents, the grounding principles of the health system, including solidarity, have also been compromised. According to a 2021 national survey on the COVID-19 pandemic and its impact on service provision, patients identified medical staff shortages, poor facilities, and insufficient funds as the most pressing problems in health care (Trend Research Centre, 2021). Meanwhile, a 2016 Eurofound survey on the quality of health and care services ranked Bulgaria among the lowest performing on most quality dimensions, with more pronounced dissatisfaction with the quality of hospital and specialist care. There is also no medical error reporting or risk management system in Bulgaria, indicating insufficient competence in the field of patient safety, which may influence patient perceptions and satisfaction with health care. BULGARIA16 FIG. 9 HOSPITAL DISCHARGES BY HEART FAILURE, INPATIENTS, PER 100 000 POPULATION, 2010 AND 2019 (OR LATEST) Note: 2016 latest year for Luxembourg, 2018 latest year for Germany, Malta and Finland. 2019 baseline year for Belgium. No data for 2019 is available for Denmark. Source: Eurostat, 2022 (data refer to 2019 or nearest year). BOX 7 | ARE PUBLIC HEALTH INTERVENTIONS MAKING A DIFFERENCE? Despite national cancer screening programmes and protocols, screening rates are low in Bulgaria. For example, in 2009, cervical cancer screening was introduced nationally; however, only 13.4% of women aged 20–69 years had been screened in the past two years in 2017.Biennial breast cancer screenings were established for women over 50 in 2011, additional to usual care, and though improved, screening rates remain low compared to the EU average. Similarly, prostate-specific antigen cancer tests were introduced for men over 50 in 2011; in 2014, fewer than 30% of the target population were screened. High levels of mortality from stroke, cardiovascular disease, and lung cancer are associated with high prevalence of behavioural risk factors in Bulgaria, attributed partially to a lack of preventive programmes. The National Programme for Prevention of Chronic Non-communicable Diseases (2014–2020) was renewed for 2021–2024. Bulgaria earmarks 1% of excise duties on tobacco and alcohol products to fund national primary pre- vention programmes. Other legislation to reduce smoking includes bans on public smoking and on sales to minors; restrictions on tobacco advertising; and warnings/images on packaging. Yet weak enforcement of legislation and insufficient information campaigns limit progress. The child obesity rate was equal to the EU average in 2018 (19%) and is a growing public health concern. The Healthy Kids Project and the National Strategy for Physical Education and Sports Development 2012–22 aim to tackle this issue. 0 300 600 900 1 200 1 500 Belgium Latvia Cyprus Ireland Denmark Spain Croatia Netherlands Luxembourg Austria Slovenia Sweden Hungary Italy Lithuania France Malta Czechia Finland Slovakia Romania Germany Poland Bulgaria Portugal 2010 2019 Hospital discharges per 100 000 inhabitants HEALTH SYSTEM SUMMARY: 2022 17 HEALTH SYSTEM OUTCOMES Unlike EU trends, preventable mortality (deaths from causes that could be avoided through public health policies) increased in Bulgaria between 2001 and 2019. In 2019, the preventable mortality rate reached 231 per 100 000, far above the EU average (160 per 100 000) (Fig. 10), driven by stroke (19% of all preventable deaths), lung cancer (16%), alcohol-related disease (16%), ischae- mic heart disease (15%), and accidents (15%). Notably, mortality from ischaemic heart disease dropped over 30% between 2005 and 2014. Mortality from treatable causes (deaths due to lack of timely and efficient care) was 189 per 100 000 in 2019, below 2011 values, but still more than twice the EU average (Fig. 10.), and for which premature deaths from stroke and ischaemic heart disease are predomi- nant causes. Like the EU, standardized death rates (SDR) relat- ing to cancer decreased between 2005 and 2015, fall- ing, however, by 3% compared to the 10% in the EU. Moreover, despite gradual increases in the last decades, 5-year survival rates for the most prevalent cancers remain among the lowest in the EU, including lung and prostate, cervical, and leukaemia, colon and breast cancer. These outcomes can be attributed in part to shortcom- ings in early detection, diagnosis, and treatment as well as a paucity of resources or planning (Box 7). FIG. 10 MORTALITY FROM PREVENTABLE AND TREATABLE CAUSES PER 100 000 POPULATION 2011 AND 2019 Note: Data are for 2011 and 2019 or latest available year. Data for France is from 2017; and from 2018 for Malta and the United Kingdom. Source: Eurostat, 2022. 2011 2019 Amenable mortality Preventable mortality 0 50 100 150 200 250 Switzerland Iceland Norway Sweden Netherlands France Spain Luxembourg Italy Belgium Denmark Finland Ireland Slovenia Austria Cyprus Portugal Germany Malta United Kingdom EU27 Greece Czechia Croatia Estonia Poland Slovakia Hungary Lithuania Latvia Bulgaria Romania 0 50 100 150 200 250 300 350 400 Cyprus Italy Malta Switzerland Iceland Spain Sweden Luxembourg Norway Netherlands Ireland France Portugal Greece Belgium Germany United Kingdom Denmark Austria Finland EU27 Slovenia Czechia Poland Bulgaria Slovakia Croatia Estonia Lithuania Romania Latvia Hungary BULGARIA18 HEALTH SYSTEM EFFICIENCY Bulgaria is the lowest spender on health per capita, while the share of GDP allocated to health ranked 12th in the EU (including the UK) in 2019. It also has the second-highest treatable mortality rate in the EU. Compared to other countries with similar levels of treatable mortality (Romania, Lithuania, Latvia), Bulgaria spends less on health (Fig. 11). Altogether, this provides a strong case for both an overall increase in health spending and for targeted measures to improve allocative efficiency. In 2015 and 2016, specific attempts to strengthen allocative efficiency were made, including the introduction of HTA and the shifting of some services from inpatient to outpatient settings (Box 5). Yet there are still several opportunities for efficiency gains. In contrast to many countries in Europe that have seen a shift towards out- patient care, and despite a stated objective to strengthen outpatient care, Bulgaria has seen, in parallel, extensive development of hospital care, partially driven by private sector expansion, and has the highest hospital admission rate in the EU. Meanwhile, the average length of hospital stay is relatively short (5.1 days in 2016) compared with the EU average (8.2 days in 2014), likely due both to the high prevalence of acute hospital beds and clinical pathways predefining the length of stay. Moreover, referral quotas serve as deterrents to accessing outpatient care. Important gains in efficiency increases can also be made in the pharmaceutical sector (Box 8). FIG. 11 AMENABLE MORTALITY PER 100 000 POPULATION VERSUS HEALTH EXPENDITURE PER CAPITA, BULGARIA AND SELECTED COUNTRIES, 2019 Am en ab le m or ta lit y pe r 1 00 0 00 p op ul at io n Health expenditure US$ PPP per capita 0 1 000 2 000 3 000 4 000 5 000 6 000 0 50 100 150 200 250 Bulgaria Hungary Greece Slovenia Denmark Note: Data is for 2019 except for France (2017), Malta (2018) and United Kingdom (2018). Source: Eurostat, 2022. HEALTH SYSTEM SUMMARY: 2022 19 Summing up The Bulgarian health system is characterized by a high level of centralization and a single payer to administer social health insurance. Health financing as a share of GDP and per capita is lower than regional average, despite continuous growth. Overall, Bulgaria has made gains on some health indicators, including mortality from treatable causes and SDRs for cancer. However, progress generally lags behind the EU. Preventable and treatable mortality are well above EU average rates, reflecting weak primary prevention and health promotion activities, and an under-developed primary health care system. Additionally, gaps in mandatory insurance coverage, high OOP spending, and self-reported unmet needs reflect challenges to accessi- bility and low degrees of financial protection, especially experienced across socioeconomic and regional fault lines. There are regional (and specialty) imbalances in health workforce, with urban areas in high concentration, and accessibility to physicians is further deteriorating due to emigration and ageing. Despite a political climate that makes systemic reforms difficult, Bulgaria has successfully made several changes to make the health system more efficient, including the introduction of HTA. The COVID- 19 pandemic highlighted the need for additional investment in the health sector, including in workforce, health information systems, and primary care. Facilitated by COVID-19, Bulgaria introduced e-referrals and e-prescription systems, and works to strengthen primary, mental health, and integrated care.. BOX 8 | IS THERE WASTE IN PHARMACEUTICAL SPENDING? Pharmaceutical spending has remained stable in Bulgaria since 2005. However, despite being one of the smallest in the EU, the market has grown substantially, and the pharmaceutical industry is one of the fast- est growing sectors of the Bulgarian economy, in part due to economic growth and high pharmaceutical prices and spending. Reference prices are derived from the lowest manufacturer prices registered across 10 countries (Belgium, France, Greece, Italy, Latvia, Lithuania, Romania, Slovakia, Slovenia and Spain). The insured pay the dif- ference between the NHIF reimbursement levels and the retail price (the reference price) out-of-pocket. NHIF tariffs are determined according to the NHIF budget, which includes a cap for outpatient medicines. In 2019, pharmaceutical spending accounted for 34.4% of total health spending in Bulgaria, almost three times the average spending in the EU (13.9%). Meanwhile, outpatient medicines accounted for about two thirds of all OOP spending. As there is no incentive for rational prescribing and no mandatory INN prescrib- ing or prescribing of the lowest-cost medicines, there is considerable scope for improving the efficiency of pharmaceutical spending overall and, concomitantly, financial protection in Bulgaria. Despite recent improvements, the prevalence of high-risk behaviours, OOP spending, and overly hospital-centric care constrains health system performance. Activities to strengthen primary, integrated care and HIS urgently need further investment. REFERENCES Dimova A and García-Ramírez JA (2022). Can people afford to pay for health care? New evidence on financial protection in Bulgaria. Copenhagen: WHO Regional Office for Europe. Eurofound (2021). Quality of health and care services in the EU. Publications Office of the European Union, Luxembourg. Eurostat (2022). Eurostat Database. European Commission, Luxembourg. OECD (2022). OECD Statistics. Paris: OECD Publishing. OECD/EU (2021). Health at a Glance: Europe 2021 – State of Health in the EU Cycle. Paris: OECD Publishing. OECD/European Observatory on Health Systems and Policies (2021), Bulgaria: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels. Republic of Bulgaria, Ministry of Health (MoH) (2022). NHS Strategy 2030. Available at: https://www.mh.government. bg/media/filer_public/2022/07/26/proekt_nzs_2030_.pdf Republic of Bulgaria, MoH. News. Minister Ananiev presented two options for changes in the health insurance model. September 26, 2018. Available at: https://www.mh.government.bg/bg/novini/ aktualno/ministr-ananiev-predstavi-dva-varianta-za-promeni-/ Republic of Bulgaria, National Statistical Institute. Health establishments as of 31.12. December 2021. Available at: Health establishments as of 31.12. | National statistical institute (nsi.bg) Trend Research Centre. The impact of the COVID-19 pandemic on health care and health services. July 2021. Available at: https://rctrend.bg/project/209684/ WHO (2022). Global Health Expenditure Database. Geneva. World Bank (2022). World Development Indicators database. Washington DC. POPULATION HEALTH CONTEXT KEY MORTALITY AND HEALTH INDICATORS LIFE EXPECTANCY (YEARS) Life expectancy at birth, total 73.6 Life expectancy at birth, male 69.9 Life expectancy at birth, female 77.5 MORTALITY (PER 100 000) All causes 1 588.5 Circulatory diseases* 1 075.9 Malignant neoplasms* 232.5 Communicable diseases* External causes of death (suicide and road accidents)* 2 394.0 Infant mortality rate (per 1 000 live births) 5.1 Maternal mortality rate (per 100 000 live births) 7.0 Notes: *Age-adjusted rates with the European standard population 2010. Life expectancy data are for 2020. Mortality data are for 2019. External causes of death data are from 2018. Infant mortality data are for 2020. Maternal mortality data are from 2014. Source: Eurostat, 2022; World Bank, 2022 for maternal mortality. Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration BULGARIA The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory’s products are available on its web site (http://www.healthobservatory.eu). © World Health Organization 2022 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies). All rights reserved. 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