State of Health in the EU Country Health Profile 2017

European

on Health Systems and Policies a partnership hosted by WHO The Country Health Profile series Contents The State of Health in the EU profiles provide a concise and 1 • HIGHLIGHTS 1 policy-relevant overview of health and health systems in the EU 2 • 2 Member States, emphasising the particular characteristics and 3 • RISK FACTORS 4 challenges in each country. They are designed to support the efforts of Member States in their evidence-based policy making. 4 • THE 6 5 • PERFORMANCE OF THE HEALTH SYSTEM 9 The Country Health Profiles are the joint work of the OECD and 5.1 Effectiveness 9 the European Observatory on Health Systems and Policies, in 5.2 Accessibility 11 cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by Member 5.3 Resilience 12 States and the Health Systems and Policy Monitor network. 6 • KEY FINDINGS 16

Data and information sources The data and information in these Country Health Profiles are The calculated EU averages are weighted averages of the based mainly on national official statistics provided to Eurostat 28 Member States unless otherwise noted. and the OECD, which were validated in June 2017 to ensure the highest standards of data comparability. The sources and To download the Excel spreadsheet matching all the methods underlying these data are available in the Eurostat tables and graphs in this profile, just type the following Database and the OECD health database. Some additional data StatLinks into your Internet browser: also come from the Institute for Health Metrics and Evaluation http://dx.doi.org/10.1787/888933593399 (IHME), the European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.

Demographic and socioeconomic context in Bulgaria, 2015

Bulgaria EU

Demographic factors Population size (thousands) 7 178 509 394 Share of population over age 65 (%) 20.0 18.9 Fertility rate¹ 1.5 1.6

Socioeconomic factors GDP per capita (EUR PPP2) 13 600 28 900 Relative poverty rate3 (%) 15.5 10.8 Unemployment rate (%) 9.2 9.4

1. Number of children born per woman aged 15–49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 50% of median equivalised disposable income.

Source: Eurostat Database.

Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors any territory, to the delimitation of international frontiers and boundaries and to the name of any and do not necessarily reflect the official views of the OECD or of its member countries, or of the territory, city or area. European Observatory on Health Systems and Policies or any of its Partners. The views expressed Additional disclaimers for WHO are visible at http://www.who.int/bulletin/disclaimer/en/ herein can in no way be taken to reflect the official opinion of the European Union. This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over

© OECD and World Health Organization (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) 74.7 74.7 PPP) (EUR spending capita Per coordination. coordination. and quality service health improve to scope great indicates this hospitalisations), avoidable rates, survival (e.g. indicators other with Together Bulgaria. in high very remains mortality Amenable Effectiveness increase efficiency. Nevertheless, challenges in terms of access and quality remain substantial. remain quality and access of terms in challenges Nevertheless, efficiency. increase to and care hospital on over-reliance away from system health Bulgarian the shift to attempted have reforms recent Several expectancy. low life by persistently shown as countries, EU other in than slowly more improved has Bulgaria in of people status health The 300 200 250 150 350 100 €2 000 €3 000 €1 000 Amenable mortality per 100 000 population 000 100 per mortality Amenable 2005 €0 1 175 351 2005 YEARS Highlights Binge drinking Binge Life expectancy at birth, years at birth, expectancy Life 2007 Smoking Obesity % of adults in 2014 in adults % of 2009

80 72 82 78 70 76 74 2000 2011 14% 71.6 77.3 17% 2013 BG BG 28% BG BG 74.7 80.6 126 289 2015 2015 EU EU 2014 EU EU Health systemperformance Health system Risk factors Health status income groups. groups. income for lower especially barriers, important remain of doctors availability and distance Travel reasons. for financial quintiles income all across problems access to point care for medical needs Unmet Access EU BG sector. informal alarge and individuals uninsured many low incomes, to due narrow remains (SHI) Insurance Health Social for the base revenue The coverage. insurance lack population of the 12% Some EU. the in highest –the –48% payments out-of-pocket high exceptionally has Bulgaria and financed is publicly expenditure health of total half Roughly 2797). (EUR average EU the half than less care, 1117 health on EUR head per spent 2015,In Bulgaria effective. been not have yet risk factors mitigate to efforts Legislative adolescents. male among particular quickly, in rising but is low obesity of Prevalence highest. fifth is the consumption alcohol capita per overall but countries EU other in lower than are consumption), alcohol for excessive ameasure (as drinking of binge day. Levels every tobacco smoking Bulgaria in of adults 28% with EU the in highest the were 2014, rates In smoking groups. socioeconomic between status health in differences large has also Bulgaria regions. across mortality infant in six-fold differences to by up exemplified as exist inequalities regional vast Furthermore, deaths. all of four-fifths than more cause cancer and diseases Cardiovascular average. EU the below 6years almost and EU, the in lowest second is 74.7 the 2015, in was which years at birth expectancy Life 0% % reporting unmet medical needs, 2015 needs, medical unmet % reporting High income 4% All Low income 8% STATE OFHEALTH INTHEEU: COUNTRY HEALTH PROFILE2017 – 16% need more time to become effective. effective. become to time more need reforms these but is encouraging, reforms of recent direction afew –the but name to shortages, workforce and migration professional mobilisation, revenue society, ageing –afast of challenges range wide the Given accountability. and of governance terms in made been has progress Some Resilience Highlights BULGARIA . 1

Bulgaria 2 . Health in Bulgaria

Bulgaria 2 Health in Bulgaria

Life expectancy at birth has increased, but 80% higher than the European average (6.6 deaths per 1 000 remains below the EU average births versus 3.6 in 2015). What is more, the worst performing region (Yambol) recorded an infant mortality rate that is six times At 74.7 years, life expectancy at birth in Bulgaria is the second higher than the best performing region (the capital Sofia) in 2016 lowest in the EU (after Lithuania), and almost 6 years lower than (National Statistical Institute, 2017) (Section 5.2). the EU average (Figure 1). Furthermore, with 3.1 years gained, improvements in life expectancy since 2000 have not been as The difference in life expectancy by socioeconomic factors, such as rapid as in most other countries. Life expectancy at birth for women level of education, is particularly large in Bulgaria. Life expectancy remains the lowest in the EU, although women recorded a steeper at birth for university-educated is seven years higher increase than men. As of 2015, the gender gap is seven years. than for those with no more than lower secondary education.1

Bulgaria has relatively high maternal mortality rates (although the 12 deaths per 100 000 births recorded in 2013 seems to be 1. Lower education levels equate to people with less than primary, primary or lower secondary education (ISCED levels 0–2) while higher education levels refer to people with an exception compared to other years). Infant mortality is over tertiary education (ISCED levels 5–8).

Figure 1. Bulgaria has the second lowest life expectancy at birth across all EU countries Bulgaria Years 2015 2000 90 74.7years of age

85 EU Average 80.6 years of age 83.0 82.7 82.4 82.4 82.2 81.9 81.8 81.6 81.6 81.5 81.3 81.3 81.1 81.1 81.0 80.9 80.8 80.7 80.6

80 78.7 78.0 77.5 77.5 76.7 75.7 75.0 74.8 74.7 75 74.6

70

65

60 EU Italy Spain Malta Latvia France Cyprus Poland Ireland Greece Austria Croatia Finland Estonia Sweden Belgium Portugal Hungary Slovenia Romania Denmark Germany Bulgaria Lithuania Netherlands Luxembourg Czech Republic Slovak Republic Source: Eurostat Database United Kingdom

A large part of the gains in life expectancy since 2000 have been Cardiovascular diseases and cancer cause after the age of 65, with the life expectancy of Bulgarian women more than four-fifths of all deaths at age 65 reaching 17.6 years in 2015 (up from 15.3 years in 2000) and that of men reaching 14.0 years (up from 12.7 years in Despite decreases since 2000, deaths from cardiovascular 2000). At age 65, Bulgarian women can expect to live more than diseases remain the leading cause of death for both women and half (54%) of their remaining life years free of disability, while men (Figure 2) and are far above the EU average. Cancer is the men can expect to live slightly less than two-thirds (62%) of them second leading cause of death, accounting for 19% of all deaths without disability.2 among men and 14% of all deaths among women, which is below the EU average and slightly increasing. Deaths from diseases of the digestive system caused 5% of all deaths in men (2% in women) and deaths from respiratory diseases 4% in men and 3% in women. 2. These are based on the indicator of ‘healthy life years’ which measures the number of years that people can expect to live free of disability at different ages.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – BULGARIA Health in Bulgaria . 3

Figure 2. Over 80% of both men’s and women’s deaths are caused by cardiovascular diseases or cancer Bulgaria Women Men (Number of deaths: 51 955) (Number of deaths: 56 244)

2% 4% 2% 7% 7% 3% 5% Cardiovascular diseases Cancer 4% Respiratory diseases 14% Digestive system External causes Other causes 19% 62% 71%

Note: The data are presented by broad ICD chapter. Dementia was added to the nervous system diseases’ chapter to include it with Alzheimer’s disease (the main form of dementia).

Source: Eurostat Database (data refer to 2014).

Figure 3. Cardiovascular diseases and cancers are the main contributors to overall mortality

2000 ranking 2014 ranking % of all deaths in 2014 1 1 Other heart diseases 23%

2 2 Stroke 21%

3 3 Ischaemic heart diseases 12%

4 4 Lung cancer 3%

5 5 Colorectal cancer 2%

6 6 Liver diseases 1%

7 7 Diabetes 1%

8 8 Pneumonia 1%

9 9 Breast cancer 1%

10 10 Lower respiratory diseases 1%

12 12 Stomach cancer 1%

Source: Eurostat Database.

Looking at more specific causes of deaths, heart diseases and Many chronic conditions are among the stroke remain the leading causes of mortality (Figure 3) and leading determinants of disability-adjusted are three times as high as the EU average. In 2014, deaths from cancers — with lung cancer as the leading cause of cancer life years mortality – were below the EU average. Deaths from colorectal A range of conditions, including musculoskeletal problems and breast cancer, as well as chronic liver diseases, have increased (including low back and neck pain, and osteoarthritis), diabetes, steadily and were above the EU average in 2014. On a more sense organ diseases (including hearing loss), diseases of the positive note, deaths from diseases of the musculoskeletal respiratory system and mental health problems (including system, diabetes, asthma and allergies are far below EU average. depression and anxiety disorders), are leading causes of disability- And deaths from dementia (including Alzheimer’s disease) are the adjusted life years (DALYs)3 lost in Bulgaria (IHME, 2016). lowest in the EU. Based on self-reported data from the European Health Interview 3. DALY is an indicator used to estimate the total number of years lost due to specific diseases and risk factors. One DALY equals one year of healthy life lost (IHME). Survey (EHIS), 3 in 10 people in Bulgaria live with hypertension,

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – BULGARIA Bulgaria socioeconomic disparities. older peoplewithlower educationallevels; however, thisalonedoesnotaccountfor all 4. Inequalitiesby educationmaypartiallybeattributedtothe higherproportionof level by income status health self-reported in differences large are There 4. Figure STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 – Source: same. the roughly are population income high the and population total the for shares The 2. same. the roughly are population income low the and population total the for shares The 1. lowest the in of Bulgarians half only is wide: status socioeconomic of different groups between gap the Again, for women). 62% versus for men (69% health good in be to themselves consider women than men More (67%). average EU the to (65%) is close health good in be to reporting population of the proportion the Overall, groups whenreportingontheirhealth There isawidevariationbetweenincome of education. level highest the with those as or asthma diabetes with live to likely as twice almost are of education level lowest the with People level. by education diseases chronic other and of these prevalence the in exist disparities Wide EU. the in than respondents Bulgarian among severe are that episodes depressive of self-reported prevalence is ahigher (2014). there depression Additionally, chronic with live people 100 3in and asthma with live people 100 3 in 4 United Kingdom Slovak Republic . Czech Republic Health in Bulgaria Health inBulgaria Luxembourg Netherlands Eurostat Database, based on EU-SILC (data refer to 2015). to refer (data EU-SILC on based Database, Eurostat Lithuania Bulgaria Germany Denmark Romania² Slovenia Hungary Portugal Belgium Sweden Estonia Finland Croatia Austria Greece¹ Ireland Poland Cyprus France Latvia Malta Spain¹ Italy¹ EU 20 4

Low income 30 % ofadultsreportingtobeingoodhealth 40 50 Total population 60 70 BULGARIA High income 80 90 100 one of the highest in Europe (ECDC, 2016). (ECDC, Europe in highest of the one 3.2%, is donors blood first-time among BVirus Hepatitis the Lastly, 2017). 2011 since (ECDC, 40%) than more (by population 000 100 per mortality TB estimated has as 30%), almost (by decreased has cases relapse and of new rate (2015), average the EU the twice are rates notification (TB) tuberculosis while Furthermore, average. EU below remained have AIDS from deaths of this, spite In EU. the across decrease overall an to contrast is in which 2004, since five-fold nearly increased has it average, EU the below remains rate notification HIV the While population. Bulgarian of the health the to threats major pose to continue diseases infectious Several challenging Infectious diseasescontinuetobe 4). (Figure quintile income highest the within five in four to compared good, be to health their consider quintile income into effect just recently (see Section 5.1). Section (see recently just effect into came policies tobacco-control 5). New Figure (see smokers regular –are EU the in level highest –the girls of 15-year-old 30% while (21%, EU Croatia), the after in prevalence smoking second-highest the have boys 15-year-old high: similarly are rates smoking Youth smokers. daily are (35%) men, three in one than more including population, adult of the 28% than less No average. EU the above points percentage seven nearly and EU, the in highest is the population Bulgarian the in of smoking prevalence The remain wellabove theEUaverage Smoking ratesandalcoholconsumption 2016). (IHME, Bulgaria in health poor to most the contribute index mass body ahigh and smoking risks, dietary factors, risk all Of activity. low physical and risks dietary consumption, alcohol smoking, including factors, risk behavioural to of DALYs) attributed terms be in can (measured Bulgaria in of disease burden overall of the 40% At least factors. risk behavioural and environment physical the conditions, working and living including determinants, of health arange to connected be can Bulgarians of many status health poor The mass indexaremajorcausesofpoorhealth High bloodpressure,diet,smokingandhighbody 3 Riskfactors percentage points higher in Bulgaria than across the EU. the across than Bulgaria in higher points percentage is 11 figure self-reported this boys, Among 15-year-olds. among drunkenness repeated of terms in fifth ranking again Bulgaria with adolescents, among consumption is alcohol concern Another 2litres. than by more average EU the 2014, in head exceeding per of alcohol litres 12 than more consumed Bulgarians EU. the in highest fifth is the consumption alcohol capita per countries, 5. Bingedrinkingbehaviour isdefinedasconsumingsixormorealcoholic beveragesonasingleoccasion,atleast onceamonthover thepast year. design: (Chart 2013–14. in survey HBSC and MeS). Laboratorio Statistics Health 2014), OECD around or in (EHIS Database Eurostat on based calculations OECD Source: is there as area’ areas. all ‘target in white the in is countries all in country No progress for room countries. EU other to compared performs country the better the centre the to is dot the closer Note: The factors risk behavioural most on poorly performs Bulgaria countries, EU other to 5.Compared Figure adult. an as or obese overweight becoming with correlated is strongly adolescence and childhood during or obese overweight being that given concerning particularly are developments These 28%. at Greece), and Malta (after EU the in highest third the now is boys among (12%),prevalence girls the low among remains indicator this While 20%. 2013–14, and reached and 2005–06 between by two-thirds rose adolescents among obesity and of overweight levels troublingly, More 2008. since by 25% risen have they average, EU the below are levels obesity adult Although male adolescents Obesity levelsarelow, butclimbingamong drinking of binge levels While Physical activity,15-year-olds Physical activity,adults Obesity, adults 5 are lower than in other EU EU other in lower than are Overweight/obesity, 15-year-olds Smoking, 15-year-olds notably the Regional Health Maps (see Box 1). Box (see Maps Health Regional the notably most attempted, been have inequities regional and inequalities socioeconomic reduce to seeking Policies 5.2). Section also (see (Dimitrov, 2014) problems access to relates also probably that afactor status, health bad disproportionately experiences show studies some which population), (5% of the minority Roma the is concern Another population. higher-educated of the that than higher points percentage is five Bulgarians of lower-educated rate obesity the adults: among for obesity case the is particularly This behaviours. health risky in engage to prone more are or education by income disadvantaged Populations groups prevalent amonglower educationorincome Some behaviouralriskfactorsaremore basis. adaily on activity physical to-vigorous moderate- in engaging report 25% than less although countries, EU other in than activity physical regular report Bulgaria in girls and boys of 15-year-old percentage ahigher note, apositive On Binge drinking,adults STATE OFHEALTH INTHEEU: COUNTRY HEALTH PROFILE2017 – Smoking, adults Drunkenness, 15-year-olds Risk factors BULGARIA . 5

Bulgaria 6 . The health system

Bulgaria 4 The health system

Bulgaria’s Social Health Insurance system is Services Agreement, 2015). These numbers need to be treated highly centralised with caution, however, as registration systems are weak and many of those counted as uninsured may be living abroad. In 1998, Bulgaria introduced a centralised SHI system, a decision that ran in parallel with the country’s transformation from a Strengthening purchasing and care centrally planned economy to a market economy. The Ministry of Health is responsible for overall organisation and policy coordination are key aims formulation, while the National Health Insurance Fund (NHIF) is the New reforms have aimed to strengthen the purchasing process in core purchaser in the system. By law, all citizens are required to Bulgaria. The main purchaser of health services is the NHIF, which obtain insurance and have a right to access care. operates through 28 Regional Health Insurance Funds. A National Framework Contract signed with national provider associations A persistently high share of citizens remains governs the relationship between the NHIF and providers. Since uninsured 2015, there have been plans to allow selective contracting of hospitals if the capacity exceeds population needs as defined by In 2013, an estimated 12% of the population did not have SHI National and Regional Health Maps (see Box 1). coverage (Advisory Services Agreement, 2015). Moreover, if citizens fail to pay three monthly contributions in the previous 36 months, Furthermore, changes to the Law on Health introduced the they lose coverage. This especially puts vulnerable groups, such as concept of integrated care (2015). This law established and the long-term unemployed and the poor at risk. Furthermore, some allowed a new type of provider, integrated social and may not be aware of their eligibility to receive government funded health service centres for children with disabilities and chronic SHI contributions. conditions. Although implementation has yet to start, it has the potential to overhaul the delivery of care. Lack of insurance is particularly prevalent among the Roma population, of which 35% have no health coverage (Advisory

Figure 6. Bulgaria is one of the lowest spenders on health in Europe

EUR PPP % of GDP Per capita (le axis) Share of GDP (right axis) 6 000 12

5 000 10

4 000 8

3 000 6

2 000 4

1 000 2

0 0 EU Italy Spain Malta Latvia France Cyprus Poland Ireland Greece Austria Croatia Finland Estonia Sweden Belgium Portugal Hungary Slovenia Romania Denmark Germany Bulgaria Lithuania Netherlands Luxembourg Czech Republic Slovak Republic United Kingdom

Sources: OECD Health Statistics, Eurostat Database, WHO Global Health Expenditure Database (data refer to 2015).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – BULGARIA Source: hospital. in working those includes only it as under-estimated is nurses of number the Greece, and Note: of nurses low numbers very has workforce 7. health Figure Bulgarian The which is the second lowest share in the EU after Cyprus. In 2017,In after EU Cyprus. the in share lowest second is the which (51%) half sources, public About from came of 9.9%. average EU of GDP, 8.2% to the below well translates 6). This 2015 (Figure in EU the in lowest third the was expenditure health Bulgaria’s power), for purchasing 2015 in (adjusted 1117At EUR capita per reliant onout-of-pocket payments Health spendingisverylow andstrongly 2017), increase the risk of significant implementation delays. implementation of significant risk the 2017), increase (March policies government’s elected newly the surrounding uncertainty with coupled decision, This grounds. technical rather and administrative on based criteria these repealed Court However, May 2017, in Administrative Supreme the meaning. apractical maps the gave it as important highly was step formal This hospitals. with contract selectively can NHIF of the branches regional the which under criteria and rules the defined of Ministers Council later,A year the care. inpatient and (or ambulatory) outpatient in population the of needs the for defining instrument an as introduced were Maps Health Regional and National 2015,In the Practising nurses per 1 000 population, 2015 (or nearest year) 1. BOX In Portugal and Greece, data refer to all doctors licensed to practice, resulting in a large overestimation of the number of practising doctors (e.g. by around 30% in Portugal). In Austria Austria In Portugal). in 30% around by (e.g. doctors practising of number the of overestimation alarge in resulting practice, to licensed doctors all to refer data Greece, and Portugal In 10 15 20 Eurostat Database. Eurostat 0 5 1 MAPS BEMAPS IMPLEMENTED? HEALTH REGIONAL AND NATIONAL THE WILL Nurses Low Doctors Low Nurses High Doctors Low 2 PL Practising doctorsper1000population, 2015(ornearestyear) RO UK IE SI HR BE 3 LU LV HU EU average:3.6 FR SK FI EE NL EU CY CZ DK ES IT MT proportion of dentists is among the highest in Europe. Europe. in highest the is among of dentists proportion the while average, EU the above is well of midwives density contrast, In level. at EU 30.2% to (GPs) compared practitioners general are 15.6% only is high, of physicians proportion the Although 7). (Figure EU the in of nurses proportion lowest second the but of physicians proportion high acomparatively has Bulgaria shortages andapersistentmigrationproblem The workforce ischallengedby severe human resource development and health infrastructure. infrastructure. health and development resource human as well as processing, and collection data in building for capacity is used which Fund, Investment and Structural European is the them Among spending. for 1% health account of total sources External services. by hospital followed payments out-of-pocket of share largest the absorb Pharmaceuticals 5.2). Section (see access care for health implications adverse has this Inevitably, EU. the in average a15% to compared expenditures, of health for 48% accounted spending out-of-pocket Indeed, EU. the in highest is the Bulgaria in payments of out-of-pocket level The 5.1). Section (see care outpatient strengthening and efforts promotion for health earmarked money byadditional 7.7%, the with increased was budget NHIF the 4 Bulgaria DE SE STATE OFHEALTH INTHEEU: COUNTRY HEALTH PROFILE2017 – LT PT 5 AT 6 The healthsystem EU average:8.4 Doctors High Doctors High EL Nurses High Nurses Low BULGARIA 7 . 7

Bulgaria Bulgaria STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 – the being States United the and France Germany, with abroad, worked Bulgaria in trained had who doctors medical 2 636 2015, In at low pay home. and low recognition to due abroad go professionals Moreover, many concern. along-standing been has workforce health the entering of graduates low numbers The 2015). to refers (data Database Eurostat Source: Note: EU the in population 1000 per discharges of inpatient number highest the has Bulgaria 8. Figure 8 Inpatient dischargesper1000population 100 150 200 250 300 350 . 50 The healthsystem 0 These values have been estimated by OECD to calculate the EU28 weighted average. 2. Estimated values. values. Estimated 2. average. weighted EU28 the calculate to OECD by estimated been have values These

Bulgaria Austria Germany Lithuania Romania Czech Republic Slovak Republic Hungary Greece¹

BULGARIA Latvia Slovenia France¹ Croatia EU¹ lacking (BAHPN, 2017). (BAHPN, lacking are data exact but for nurses exists trend asimilar Association, Nursing Bulgarian the to (OECD, 2016). According workforce GP employed currently of the half than more constitutes and 2003 since a six-foldincrease reflects This destinations. popular most (2015) as compared to an EU average of 4.2. of 4.2. average EU an to compared (2015) as population 1000 per beds 6.0 with EU the in beds care of acute number largest of the one has Bulgaria 8). Furthermore, (Figure EU the in highest is the discharges of inpatient number the hospitals, on as over-reliance well as care primary weak Reflecting of 7.5. average EU (2015), the below capita per contacts outpatient 5.9 about have only Bulgarians Furthermore, 5.2). Section (see GP per patients of enlisted number the and of GPs density the in exists variation regional considerable However, services. inpatient and specialists outpatient to of referrals number alimited with operating gatekeepers, as act to supposed are 5.1). GPs Section 2013) also (see al., et (Kringos weak is comparatively system care primary Bulgaria’s remains dominant In healthserviceprovision, hospitalcare Estonia Poland Finland Belgium¹ Malta Sweden Denmark Luxembourg² Ireland United Kingdom Italy Netherlands¹ Spain Portugal² Cyprus Source: women and men for both Europe in highest the is among mortality 9. Amenable Figure through timelyandeffective healthcare. 6. Amenablemortalityisdefinedasprematuredeathsthatcouldhavebeenavoided respect. this in countries performing worst of the is one system health 2014, Bulgarian and the 2004 between mortality of amenable a17% reduction Despite diseases isexceptionallyhigh Amenable mortalityfromcardiovascular 5.1 EFFECTIVENESS European average of 11%. average European the than higher much avoidable, be to 2014 considered still were in deaths) of (or all 19% deaths 000 20 2014in 9). About (Figure average EU the as high as twice is about women and men both United Kingdom Slovak Republic Czech Republic Luxembourg Netherlands 5 Lithuania Bulgaria Germany Denmark Eurostat Database (data refer to 2014). to refer (data Database Eurostat Romania Slovenia Hungary Portugal Belgium Sweden Estonia Finland Croatia Austria Greece Ireland Poland Cyprus France Latvia Performance ofthehealthsystem Malta Spain Italy EU 0 Women 64.4 64.9 67.7 69.3 74.1 100 77.4 79.4 80.7 79.7 83.0 83.9 88.2 85.5 85.4 88.7 92.3 94.4 98.7 97.5 119.9 121.5 Age-standardised ratesper100000population 147.8 152.5 168.2 200 192.3 196.3 6 Amenable mortality for mortality Amenable 207.1 214.9 239.5 300 400 500 impact on population health. population on impact alarge have could and possible are treatment and prevention CVD in Improvements average. EU the below mortality all-cause push would it average, EU the to mortality CVD reduce could Bulgaria If high. very are EU) the than greater times (1.5 disease heart ischaemic average) and EU the times four (almost hypertension from rates mortality 10). addition, In (Figure France SDR, lowest the with country of the that times seven 2014in than more and average EU the times four than more was stroke) (e.g. diseases cerebrovascular from (SDR) rate death standardised The (CVDs). diseases cardiovascular from mortality high persistently is the morality of amenable rates high to contributor important most The United Kingdom Slovak Republic Czech Republic Luxembourg Netherlands Lithuania Bulgaria Germany Denmark Romania Slovenia Hungary Portugal Belgium Sweden STATE OFHEALTH INTHEEU: COUNTRY HEALTH PROFILE2017 – Estonia Finland Croatia Austria Greece Ireland Poland Cyprus France Latvia Malta Spain Italy EU 0 Men 92.1 96.4 107.9 108.2 110.5 113.7 115.1 117.0 117.2 133.0 138.0 139.1 139.6 149.0 152.1 154.4 158.2 Age-standardised ratesper100000population 160.3 168.2 200 Performance ofthehealthsystem 229.0 242.5 278.2 335.9 350.7 361.3 400 388.8 415.0 473.2 BULGARIA 501.2 . 9 600

Bulgaria 10 . Performance of the health system

Figure 10. Mortality from stroke in Bulgaria is more High rates of avoidable hospital admissions point

Bulgaria than four times the EU average to weak primary care and lack of coordination

Standardised death rate per 1 000 population Hospital admission rates due to chronic conditions, such as diabetes, 40 CVDs and diseases of the respiratory system are among the highest in the EU. Hospital (re-)admissions of patients with these conditions 35 can be effectively treated in ambulatory care. In fact, a 2013 analysis of hospitalisations suggested that at least 20% of inpatient 30 procedures performed in Bulgaria could have been conducted in outpatient settings (World Bank, 2013). Nevertheless, the inpatient 25 care sector has continued to grow since 2013.

20 There are various explanations for the high number of potentially avoidable hospital admissions, including the fact that accessibility 15 of outpatient care is limited in some regions; financial incentives encourage hospitals to treat more patients; ceilings on some 10 diagnostic referrals in primary care lead to patients being admitted for inpatient care; and patients preferring inpatient care 5 over outpatient settings (see also Section 4).

0 Bulgaria European Union France (28 countries) Unstable financing and low coverage in rural

Note: This data refers to population aged less than 65 years and comprises all areas lead to low cancer screening rates cerebrovascular diseases. According to CONCORD Programme data, five-year cancer survival Source: Eurostat Database, 2017 (data refer to 2014). rates have increased between 2000–04 and 2010–14 for cervical Another challenge is rising cancer mortality. Whereas the SDR for cancer (from 49.2% to 54.8%), breast cancer (70.9% to 78.3%) colorectal cancer is close to the EU level, for cervical cancer and colon cancer (43.9% to 52.4%) but they remain lower than in (4.7 per 100 000) it is more than double the average (2.1 per most other EU countries. Additional points of concern are the very 100 000). Furthermore, the SDR for TB remains high at 1.7, low survival rates from lung cancer (6.3% in 2005–09) and liver which is almost twice the EU average. Finally, comparatively high cancer (5%) (Allemani et al., 2015). amenable mortality rates for nephritis (8.6 in Bulgaria versus 2.4 on average in the EU) indicate that there is room for Bulgaria is still implementing nationwide mechanisms for early improvement in renal replacement therapy (dialysis). detection of non-communicable diseases. Since 2009, it has screening programmes for cervical, breast, prostate and colorectal Recent efforts to strengthen health promotion cancer. However, limited resources and a focus on treatment rather and prevention have yet to show their effects than on prevention hinder full screening coverage of the population, which up until now have focused on certain districts and high-risk A substantial proportion of deaths could be prevented by tackling groups. Indeed, in 2015, screening uptake for breast cancer and behavioural risk factors and strengthening primary prevention. In cervical cancer were 13.6% and 8.6% respectively, and even lower in particular, the prevalence of smoking and alcohol consumption in rural areas.7 Bulgaria continues to be among the highest in Europe (see Section 3). However, in 2014 alcohol-related death rates were only slightly Vaccination rates are low above EU average, as were deaths rates due to traffic accidents. Child immunisation rates are low compared to the EU average On a positive note, Bulgaria has recently scaled up health promotion and have begun to drop since 2013. In addition, there have been and prevention efforts. A smoking ban in public places was recurrent infectious disease outbreaks among the Roma population. introduced in 2012 and the National Prevention Programme (2014– In response, special vaccination programmes have been rolled out 20) focuses attention on early detection of non-communicable diseases, especially CVDs. This is supported by a budget increase 7. Self-reported data from the 2014 EHIS show higher rates: 32% of Bulgarian women in 2017, earmarked for early detection and screening. Providers are aged 50–69 reported having had a breast cancer screening over the past two years and 69% of women aged 20–69 reported having had a cervical cancer screening over the past incentivised to participate in screening, examination and prophylaxis. three years.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – BULGARIA Performance of the health system . 11

to reach vulnerable groups, such as the Roma. Uptake of influenza Figure 11. Unmet needs for medical care are high, in

vaccination among those aged 65 and over is very low in Bulgaria, particular for low-income households Bulgaria just 2.4%, the second lowest in the EU, after Estonia. High income Total population Low income Estonia Ensuring quality of care is challenging Greece Romania There is no reliable national monitoring or quality assurance Latvia system and information on quality is scarce. Many (often small) Poland hospitals lack the necessary qualified staff and technical Italy equipment (CT scanners, intensive care units) to provide high Bulgaria quality care and do not exchange data across providers. Quality Finland concerns have been repeatedly reported for both local hospitals EU and local outpatient services. However, a recent EU-funded Portugal initiative aims to develop electronic health records, electronic Lithuania referral and electronic prescription systems. Another quality- Ireland related issue is the high use of antibiotics and rising rates of United Kingdom antimicrobial resistance (see Box 2). Hungary Belgium 5.2 ACCESSIBILITY Slovak Republic Croatia Lack of affordability contributes most to Cyprus Denmark unmet needs for medical care France A considerable share of Bulgarians (4.7% in 2015) reported Sweden unmet needs for a medical examination or treatment (Figure 11), Luxembourg with financial reasons being the most important cause. Travel Czech Republic distance and the availability of doctors also remain important Malta barriers to access, especially for low income patients. In contrast, Spain Germany unmet needs for dental care are comparatively low in Bulgaria, Netherlands which may relate to the high density of dentists (see Section 4). Slovenia Austria National surveys also confirm regional inequalities, with a higher 0 10 20 share of foregone care in small towns and villages (Atanasova, % reporting unmet medical need, 2015 Mircheva and Dokova, 2016). Interestingly, waiting times are not Note: The data refer to unmet needs for a medical examination or treatment due to perceived to be an important reason for unmet needs – possibly costs, distance to travel or waiting times. Caution is required in comparing the data across because money can usually buy faster access. countries as there are some variations in the survey instrument used. Source: Eurostat Database, based on EU-SILC (data refer to 2015). The gap in population coverage is also hindering disease prevention and control BOX 2. ANTIMICROBIAL RESISTANCE IS A MAJOR PROBLEM Lack of SHI coverage creates a major barrier to access for a considerable share of the population (Section 4). Uninsured Antimicrobial resistance is a major public health threat in individuals have to pay directly for medical services and goods, Bulgaria. Surveillance data reported to EARS-Net shows that, unless they visit an emergency centre in a life-threatening in 2015, 22.9% of Streptococcus pneumoniae bloodstream situation. To limit the spread of infectious diseases among people infections were resistant to penicillin, which is much higher who lack insurance, the NHIF receives additional funding to pay for than the EU/EEA (European Economic Area) median and is the screening of uninsured individuals. rising (ECDC, 2017). A National Programme for the Rational Use of Antibiotics and Surveillance was adopted in 2016, in accordance with the National Health Strategy 2020.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – BULGARIA 12 . Performance of the health system

The basic benefit package changes BOX 3. AN ATTEMPT TO REFORM THE BENEFIT PACKAGE Bulgaria frequently which contributes to uncertainty WAS PARTIALLY STRUCK DOWN IN COURT The SHI system guarantees access to a basic package of In 2016, the benefit package was to be split into two parts: health services for the insured population. It covers primary basic and complementary. The basic part would cover and specialised outpatient medical and dental care; laboratory prophylaxis, diagnosis and treatment of major diseases and services; hospital diagnostics and treatment; and highly conditions that cause death and disability, and maternal and specialised medical activities. In addition, emergency care, child health – in accordance with the health priorities listed in inpatient mental health care, renal dialysis, in vitro fertilisation the National Health Strategy ‘Health 2020’. The complementary and transplantations are covered by the state budget or other part was to include treatment services which could be dedicated funds. Long-term care is mostly excluded. postponed without the immediate risk of a patient’s condition deteriorating, such as hip replacement surgery. In 2016, the The benefit basket is set by the Ministry of Health, while Constitutional Court rejected this proposal as unconstitutional, tariffs and payment mechanisms are specified in the National halting the reform. Less controversially, changes to the benefit Framework Contract and negotiated on an annual basis by the package were successfully made which aimed to reduce NHIF and representative organisations of physicians and hospital activity by transforming some inpatient services to dentists. Attempts to reform the benefit package failed in 2016 ambulatory procedures (performed by hospitals or outpatient (see Box 3). User charges were set in 2012, and certain frequent medical centres) and to promote the integration of services. changes in the benefits package create uncertainty among patients, and financial insecurity. pharmaceuticals); direct payments for excluded services; and Out-of-pocket payments are the highest in informal payments. Europe and threaten access for vulnerable groups Exemptions from cost sharing exist for a range of groups, including children, pregnant women, chronically sick patients and some other Out-of-pocket payments accounted for 47.7% of spending eligible groups. In addition, pensioners pay reduced user fees per visit. in 2015 – more than three times the EU average (Figure Nevertheless, financial reasons remain the most important barrier to 12). Looking at out-of-pocket payments as a share of final accessing health services, althought unmet need due to this reason household consumption provides an even more dramatic fell from 16.4% in 2006 to 3.7% in 2015. This is often blamed on picture, with Bulgaria outpacing all other countries by a the existence of informal payments (Atanasova, Pavlova and Groot, large margin (Figure 13). High out-of-pocket payments are 2015). Unmet need due to cost remains particularly high among the caused by substantial cost sharing for most covered services lowest income quintile (9.3% compared to 4.1% in the EU) and the (GPs, hospitals, services outside standard patient pathways, difference between income quintiles is among the largest in Europe.

Figure 12. Out-of-pocket spending in Bulgaria is triple that of the EU

Bulgaria EU 1% 1% 5%

Public/Compulsary 15% health insurance Out-of-pocket 48% 51% Voluntary health insurance Other 79%

Source: OECD Health Statistics, Eurostat Database (data refer to 2015).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – BULGARIA Performance of the health system . 13

Figure 13. Bulgarians spend the most in terms of final household budget on medical care Bulgaria Out-of-pocket medical spending as a share of final household consumption 7

6

5

4

3

2

1

0 EU Italy Spain Malta Latvia France Cyprus Poland Ireland Greece Austria Croatia Finland Estonia Sweden Belgium Portugal Hungary Slovenia Romania Denmark Germany Bulgaria Lithuania Netherlands Luxembourg Czech Republic Slovak Republic United Kingdom

Note: This indicator relates to current health spending excluding long-term care (health) expenditure and is displayed as percentage of final household consumption

Sources: OECD Health Statistics, Eurostat Database, WHO Global Health Expenditure Database.

A lack of personnel worsen access to health population at risk of poverty and social exclusion, almost double care in certain geographical areas the EU average of 23.8% in 2015.

There is a large variation in the distribution of providers (Figure On the other hand, per capita current health spending doubled 14), which threatens accessibility. Although the number of medical from 2005 to 2015 in nominal terms, outpacing overall economic graduates rose by more than 75% between 2005 and 2015, growth. However, low incomes, the high level of uninsured disparities in the physician workforce were not remedied for a individuals, a large informal sector, and continuing migration of number of reasons: first, most foreign medical students in Bulgaria young and well-educated people, narrows the revenue base and are likely to pursue their career in their home country; second, could threaten the stability of health system financing. Moreover, many medical graduates migrate abroad (see Section 4); and, the population is ageing fast, which is caused by low fertility rates third, providers are concentrated in a few urbanised regions. The and high levels of migration. By 2050, one in three Bulgarians is number of nursing graduates has stabilised at a very low level of projected to be 65 years or older, while only one in two Bulgarians approximately 300 per year since 2005. Given the already severe will be of working age. shortage of nurses in the country and similar migration patterns to those of medical doctors, the (regional) availability of health Better allocation and use of resources could services will suffer. potentially increase efficiency 5.3 RESILIENCE8 Bulgaria spends most of its limited resources on pharmaceuticals and inpatient care. In 2015, the country spent more than 40% of High out-of-pocket payments, unemployment total health spending on pharmaceuticals and medical goods, the and ageing threaten the system’s financial highest share in the EU and more than twice the EU average. In addition, the inpatient care sector is comparably large as share of stability total health spending (34% versus 29% in the EU), while the share The heavy reliance on out-of-pocket payments as a revenue of outpatient care spending (18%) is the smallest in the EU. source poses substantial risks for the mid- to long-term stability of the health system, in particular during times of economic crises. Efficiency could be improved by strengthening primary care and A sizable part of the population is poor and cannot afford to pay shifting provision from expensive inpatient care to outpatient and for care directly. Indeed, Bulgaria reported a 41.3% share of the day care. For example, tonsillectomies and cataract surgeries are still virtually all carried out in inpatient settings. Important gains could also be made on pharmaceutical spending (see section on 8. Resilience refers to health systems’ capacity to adapt effectively to changing environments, sudden shocks or crises. Health Technology Assessment below).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – BULGARIA 14 . Performance of the health system

Figure 14. Medical personnel are mostly concentrated in more urbanised regions Bulgaria

9 10 Silistra Vidin 8 11 8 9 Dobrich Ruse Razgrad Montana 12 14 Vratsa Pleven 10 9 10 Shumen 12 VelikoTarnovo Targovishte Varna 11 Lovech 13 10 Gabrovo 14 Sofia 8 Sofia 9 Pernik (solista) Sliven 9 13 Burgas Stara Zagara 10 14 9 Kyustendil Plodiv Yambol 9 Pazardzhik

9 9 Haskovo Population in numbers Blagoevgrad 10 91 235 - 150 000 Smolyan 9 150 001 - 200 000 Kardzhali 200 001 - 300 000 300 001 - 500 000 Medical personnel per 1 000 people in numbers 500 001 - 1 319 804 Total for country in numbers 12 Total for country in numbers 7 153 784

Source: National Statistical Institute (2017).

More resources are needed medicines belonging to new International Non-proprietary Name groups that previously are not included in the Positive Drug List.. Relating the level of amenable mortality to health expenditures Notwithstanding this, the root causes of Bulgaria’s high share shows that Bulgaria is performing in line with what can be of pharmaceutical spending need to be better understood. It is expected with current spending levels. This suggests that to most likely the result of high prices due to a lack of (centralised) actually achieve improvements in health outcomes, besides purchasing power, an overconsumption of drugs paid out of pocket polices that address risk factors and improve care, more resources and perhaps still low generic penetration. Comprehensive studies are also likely needed. Indicatively, countries spending slightly and good data are lacking. more (e.g. Croatia and Poland) have much lower amenable mortality (Figure 16). Structural reforms to contain costs and Health Technology Assessment for integrate care are in their early stages pharmaceuticals foreshadows better value Improving the efficiency of the hospital sector has been the for money focus of several recent reforms. These have sought to reduce inpatient capacity by allowing selective contracting, making Several mechanisms have been introduced or planned to reduce changes to the benefit package (see Sections 4 and 5.2), allowing pharmaceutical-related costs since 2011. In addition, the more ambulatory treatments, and fostering cost-effectiveness introduction of Health Technology Assessment (HTA) in 2015 is and quality information. Additionally, recent plans to introduce expected to (further) increase the effectiveness of pharmaceutical integrated care into the health system are encouraging (see spending. The implementation process started only in 2016, Section 4). with the establishment of a special commission at the National Centre of Public Health and Analysis. HTA is now applied for

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – BULGARIA Performance of the health system . 15

Figure 15. Bulgaria could improve amenable mortality by spending more on health Bulgaria Health expenditure per capita, EUR PPP 6 000

LU 5 000

NL 4 000 SE DE DK IE AT FR BE 3 000 FI UK IT ES MT 2 000 PT SI CZ CY EL SK EE HU LT PL HR LV 1 000 Bulgaria RO

0 0 50 100 150 200 250 300 350 Amenable mortality per 100 000 population

Source: OECD Health Statistics, Eurostat Database, WHO Global Health Expenditure Database (data refer to 2014).

Combined, these initiatives could both help to reduce inpatient Additionally, strategies for the prevention, mitigation and early care activity and increase the degree of coordination of care. detection of non-communicable diseases resulted in initial Some early results show that certain inpatient care procedures successes, such as the smoking ban in 2012. The National are now performed in outpatient settings. In light of rising chronic Prevention Programme 2014–20 continues to prioritise health conditions and complex co-morbidities, improving coordination prevention but it is too early to assess the overall impact of this across sectors could potentially improve quality and reduce costs. strategy.

The new approach to stakeholder Lastly, since 2015, an innovative forum, the Partnership for engagement in health policy making is Health, acts as a consultative body to the Council of Ministers and is chaired by the Minister of Health. Based on consultations promising with a wide range of stakeholders, it has played a key role in Bulgaria has improved its accountability mechanisms in recent reform initiatives, such as pharmaceutical policy, structural recent years. An interest among public bodies in undertaking changes in the health system, and quality of care. performance assessments has grown. The National Health Strategy (2008–13) prioritised care quality and access to health services, human resources development, as well as restructuring and efficient management of hospital care. It also laid out plans to the increase the adequacy of the financing system. The strategy sets out indicators for assessing and monitoring implementation, deadlines for activities and institutional responsibilities.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – BULGARIA Bulgaria STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 – l l l l 16

. prevention and better care coordination. coordination. care better and prevention better quality, well as care as and access by improving for example services, health improve to room substantial signals This for cancers. rates several low survival very and EU stroke) (e.g. the in diseases cerebrovascular from rate mortality highest the has Bulgaria fact, In diseases. non-communicable and cancer, diabetes from mortality arising and diseases cardiovascular as such diseases from mortality high persistently in reflected as mortality, or preventable amenable reducing in effective been not has system health The system. health of the resilience the maintain and resources limited its spend wisely strategically to have choose to will Bulgaria health. on low spending and shortages workforce population, ageing arapidly well as obesity), as increasing drinking, (smoking, factors risk behavioural high alarmingly some and (afterLithuania) EU the in life lowest expectancy second the has It simultaneously. major faces several challenges Bulgaria’s system health to ageing. ageing. to due ratio dependency adeteriorating and sector informal alarge low employment, shocks, it economic from protect to broadening needs base revenue the years, recent in overall economy the outpaced spending health in growth Although out-of-pocket high payments. very well as as spending, by lowtotal characterised is financing Health materialise. to for Yet results for is needed time example. more diseases of cardiovascular for early detection funds 2017 additional The allocates care. budget integrated introduce to attempts recently, more with and 2008, since diseases of chronic early detection and prevention health with made been positively, has More progress some Key findings 6 Keyfindings BULGARIA l l l l

income groups. groups. income lower in for especially people barriers, access important pose also Travel of availability doctors and distance Bulgaria. in present still are which payments, informal from people protect not does this exist, exemptions olderand people. some Although out-of-pocket households, lower income Roma, the including groups, for vulnerable care health to access threaten payments out-of-pocket high and insurance without are of citizens 12% Some aproblem. remains services health to Access developed. policies new and assessed properly be can spending volumes) of pharmaceutical high and prices (e.g. causes way, under root already the Technology Assessment of Health introduction the With forward. going afocus be should spending pharmaceutical Furthermore, problem. this address to have sought sector hospital the in reforms Recent care. outpatient and day in care treated be could cases more and strengthened be could care Primary care. inpatient and pharmaceuticals on resources of its most spends Currently,Bulgaria efficiency. increase to potential the has of use resources and allocation A better encouraging. encouraging. are reforms of recent implementation and direction the ahead, of challenges range wide the Given system. health Bulgarian of the accountability and governance the strengthening in made been has progress Much-needed term. long the in guaranteed be can skill mix and workforce health effective an that so needed are issues pay. these better address to Policies and prospects career of better search in countries other migrate to professionals Health of nurses. shortages large and of GPs distribution the in disparities greatare regional notably, Most there problem. migration apersistent and by shortages severe (future) is challenged The workforce Health in Bulgaria . c

Key sources Bulgaria

Dimova, A. et al. (2012), “Bulgaria: Health System Review”, Health OECD/EU (2016), Health at a Glance: Europe 2016 – State of Systems in Transition, Vol. 14(3), pp. 1–186. Health in the EU Cycle, OECD Publishing, Paris, http://dx.doi. org/10.1787/9789264265592-en. References

Advisory Services Agreement (2015), Final Report on Health Financing ECDC (2017), “Surveillance Report: Tuberculosis Surveillance and Diagnostic and Review of Envisaged Reforms 2015, Advisory Monitoring in Europe”, European Centre for Disease Prevention Services Agreement between the Ministry of Health of the and Control, Stockholm, Republic of Bulgaria and the International Bank for Reconstruction http://ecdc.europa.eu/en/publications/Publications/ecdc- and Development, https://www.mh.government.bg/media/filer_ tuberculosis-surveillance-monitoring-Europe-2016.pdf. public/2015/06/16/final-report-on-health-financing-diagnostic- and-review-of-envisaged.pdf. ECDC (2016). Systematic review on hepatitis B and C prevalence in the EU/EEA. European Centre for Disease Prevention and Allemani, C. et al. (2015), “Global Surveillance of Cancer Survival Control, Stockholm. 1995-2009: Analysis of Individual Data for 25 676 887 Patients from 279 Population-based Registries in 67 Countries IHME (2016), “Global Health Data Exchange”, Institute for Health (CONCORD-2)”, The Lancet, Vol. 385(9972), pp. 977-1010, Metrics and Evaluation, Sofia, available at http://dx.doi.org/10.1016/S0140-6736(14)62038-9. http://ghdx.healthdata.org/gbd-results-tool.

Atanasova, E., I. Mircheva and K. Dokova (2016), “Regional Kringos, D. et al. (2013), “The Strength of Primary Care in Europe: Disparities in All-cause Mortality in Bulgaria for the Period An International Comparative Study”, British Journal of General 2000-2012”, Scripta Scientifica Salutis Publicae, Vol. 2(1). Practice, Vol. 63(616), pp. e742–e750, http://dx.doi.org/10.3399/bjgp13X674422. Atanasova, E., M. Pavlova and W. Groot (2015), “Out-of-pocket Patient Payments for Public Health Care Services in Bulgaria”, National Statistical Institute (2017), “Regions, Districts and Frontiers in Public Health, Vol. 3:175. Municipalities in the Republic of Bulgaria 2015”, www.nsi.bg/en/

BAHPN (2017), “Press Release on Mobility”, Bulgarian Association OECD (2016), “Monitoring Health Workforce Migration through for Health Care Professionals, in Bulgarian: БАПЗГ, International Data Collection: Progress with Eurostat/OECD/ http://www.nursing-bg.com/aktualna.html. WHO Joint Questionnaire”, Presentation held by Gaetan Lafortune in Varna. Dimitrov, D. (2014), “Civil Society Monitoring Report on the Implementation of the National Roma Integration Strategy World Bank (2013), “Mitigating the Economic Impact of an Aging and Decade Action Plan in 2012 in Bulgaria”, Decade of Roma Population: Options for Bulgaria”, World Bank, Inclusion Secretariat Foundation, Budapest, http://documents.worldbank.org/curated/en/2013/09/18262916/ http://osi.bg/downloads/File/2013/BG_civil%20society%20 mitigating-economic-impact-aging-population-options-bulgaria. monitoring%20report_EN.pdf.

Country abbreviations Austria AT Denmark DK Hungary HU Malta MT Slovenia SI Belgium BE Estonia EE Ireland IE Netherlands NL Spain ES Bulgaria BG Finland FI Italy IT Poland PL Sweden SE Croatia HR France FR Latvia LV Portugal PT United Kingdom UK Cyprus CY Germany DE Lithuania LT Romania RO Czech Republic CZ Greece EL Luxembourg LU Slovak Republic SK

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – BULGARIA State of Health in the EU Country Health Profile 2017

The Country Health Profiles are an important step in the Each Country Health Profile provides a short synthesis of: European Commission’s two-year State of Health in the EU l  health status cycle and are the result of joint work between the Organisation l  the determinants of health, focussing on behavioural risk for Economic Co-operation and Development (OECD) and the factors European Observatory on Health Systems and Policies. This l  the organisation of the health system series was co-ordinated by the Commission and produced with l  the effectiveness, accessibility and resilience of the health the financial assistance of the European Union. system

The concise, policy relevant profiles are based on a transparent, This is the first series of biennial country profiles, published in consistent methodology, using both quantitative and qualitative November 2017. The Commission is complementing the key data, yet flexibly adapted to the context of each EU Member findings of these country profiles with a Companion Report. State. The aim is to create a means for mutual learning and voluntary exchange that supports the efforts of Member States For more information see: ec.europa.eu/health/state in their evidence-based policy making.

Please cite this publication as:

OECD/European Observatory on Health Systems and Policies (2017), Bulgaria: Country Health Profile 2017, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels. http://dx.doi.org/10.1787/9789264283305-en

ISBN 9789264283305 (PDF)

Series: State of Health in the EU ISSN 25227041 (online)

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