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Bulgaria: Health System Review 2007 Health Systems in Transition Vol. 9 No. 1 2007 Bulgaria Health system review Lidia Georgieva • Petko Salchev Rostislava Dimitrova • Antoniya Dimova Olga Avdeeva Editors: Olga Avdeeva • Melinda Elias Health Systems in Transition Written by Lidia Georgieva, MARSH Bulgaria, Sofia Petko Salchev, Department of Social Medicine and Healthcare Management, Medical University, Sofia Rostislava Dimitrova, European Parliament, Brussels Antoniya Dimova, Department of Health Management, Medical University, Varna Olga Avdeeva, European Observatory on Health Systems and Policies Edited by Olga Avdeeva, European Observatory on Health Systems and Policies Melinda Elias, European Observatory on Health Systems and Policies Bulgaria: Health System Review 2007 The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration BULGARIA © World Health Organization 2007, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about this to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/PubRequest) The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The European Observatory on Health Systems and Policies does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Printed and bound in the United Kingdom by TJ International, Padstow, Cornwall. Suggested citation: Georgieva L, Salchev P, Dimitrova S, Dimova A, Avdeeva O. Bulgaria: Health system review. Health Systems in Transition, 2007; 9(1): 1–156. ISSN 1817-6127 Vol. 9 No. 1 Health systems in transition Bulgaria Contents Preface ............................................................................................................ v Acknowledgements ...................................................................................... vii List of abbreviations...................................................................................... ix List of tables and figures ............................................................................... xi Abstract ....................................................................................................... xiv Executive summary ...................................................................................... xv 1. Introduction ................................................................................................ 1 1.1 Overview of the health system....................................................... 1 1.2 Geography and sociodemography ................................................. 4 1.3 Economic context .......................................................................... 6 1.4 Political context ............................................................................. 8 1.5 Health status .................................................................................. 9 2. Organizational structure and management ............................................... 15 2.1 Historical background .................................................................. 15 2.2 Organizational overview .............................................................. 17 2.3 Decentralization and centralization ............................................. 24 2.4 Patient empowerment .................................................................. 25 3. Financing .................................................................................................. 35 3.1 Health expenditure ....................................................................... 36 3.2 Population coverage and basis for entitlement ............................ 47 3.3 Revenue collection/sources of funds ........................................... 50 3.4 Polling of funds ........................................................................... 59 3.5 Purchasing and purchaser–provider relations .............................. 61 3.6 Payment mechanisms................................................................... 62 4. Planning and regulation ........................................................................... 69 4.1 Regulation .................................................................................... 69 4.2 Planning and health information management ............................ 76 iii Health systems in transition Bulgaria 5. Physical and human resources ................................................................. 79 5.1 Physical resources ........................................................................ 79 5.2 Human resources ......................................................................... 89 6. Provision of services ................................................................................ 99 6.1 Public health ................................................................................ 99 6.2 Patient pathways ........................................................................ 101 6.3 Primary/ambulatory care ........................................................... 103 6.4 Specialized ambulatory care/inpatient care ............................... 105 6.5 Emergency care ......................................................................... 108 6.6 Pharmaceutical care ................................................................... 111 6.7 Rehabilitation/intermediate care ................................................ 114 6.8 Long-term care .......................................................................... 115 6.9 Services for informal carers ....................................................... 116 6.10 Palliative care ........................................................................... 117 6.11 Mental health care ................................................................... 117 6.12 Dental health care .................................................................... 119 6.13 Alternative/complementary medicine ...................................... 120 6.14 Health care for specific populations ........................................ 121 7. Principal health care reforms ................................................................. 125 7.1 Analysis of recent reforms ......................................................... 125 7.2 Future developments .................................................................. 130 8. Assessment of the health system ............................................................ 139 9. Conclusions ............................................................................................ 149 10. Appendices ........................................................................................... 151 10.1 References ............................................................................... 151 10.2 HiT methodology and production process ............................... 154 iv Health systems in transition Bulgaria Preface he Health Systems in Transition profiles are country-based reports that provide a detailed description of a health system and of reform and policy Tinitiatives in progress or under development in a specific country. Each profile is produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profiles are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a profile. Health Systems in Transition profiles seek to provide relevant information to support policy-makers and analysts
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