Bulgaria BG Country Health Profile 2019 the Country Health Profile Series Contents

State of Health in the EU Bulgaria BG Country Health Profile 2019 The Country Health Profile series Contents

The State of Health in the EU’s Country Health Profiles 1. HIGHLIGHTS 3 provide a concise and policy-relevant overview of 2. HEALTH IN BULGARIA 4 health and health systems in the EU/European Economic 3. RISK FACTORS 8 Area. They emphasise the particular characteristics and challenges in each country against a backdrop of cross- 4. THE HEALTH SYSTEM 10 country comparisons. The aim is to support policymakers 5. PERFORMANCE OF THE HEALTH SYSTEM 13 and influencers with a means for mutual learning and 5.1. Effectiveness 13 voluntary exchange. 5.2. Accessibility 16 The profiles are the joint work of the OECD and the 5.3. Resilience 19 European Observatory on Health Systems and Policies, 6 KEY FINDINGS 22 in cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by the Health Systems and Policy Monitor network, the OECD Health Committee and the EU Expert Group on Health Information.

Data and information sources The calculated EU averages are weighted averages of the 28 Member States unless otherwise noted. These EU The data and information in the Country Health Profiles averages do not include Iceland and Norway. are based mainly on national official statistics provided to Eurostat and the OECD, which were validated to This profile was completed in August 2019, based on ensure the highest standards of data comparability. data available in July 2019. The sources and methods underlying these data are To download the Excel spreadsheet matching all the available in the Eurostat Database and the OECD health tables and graphs in this profile, just type the following database. Some additional data also come from the URL into your Internet browser: http://www.oecd.org/ Institute for Health Metrics and Evaluation (IHME), the health/Country-Health-Profiles-2019-Bulgaria.xls 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, 2017

Demographic factors Bulgaria EU Population size (mid-year estimates) 7 076 000 511 876 000 Share of population over age 65 (%) 20.7 19.4 Fertility rate¹ 1.6 1.6 Socioeconomic factors GDP per capita (EUR PPP²) 14 800 30 000 Relative poverty rate³ (%) 23.4 16.9 Unemployment rate (%) 6.2 7.6

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 60 % of median equivalised disposable income. Source: Eurostat Database.

Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries, or of the European Observatory on Health Systems and Policies or any of its Partners. The views expressed 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 any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.

Additional disclaimers for WHO are visible at http://www.who.int/bulletin/disclaimer/en/

2 State of Health in the EU · Bulgaria · Country Health Profile 2019 83 79 75 81 77 Life expectancy at birth,years Prevent ble % of adults the monitoring ofcare quality. data onkey indicatorshampers effectiveness ofcare. A lack of disease prevention andthe a large scopeforimproving the highestinEU, indicating causes ofmortalityare among Both preventable andtreatable Effectiveness Per capita spending(EURPPP) to shiftthehealthsystem’s focusaway from hospital-centred care. including theintroduction ofhealthtechnology assessment(HTA) for pharmaceutical reimbursement, andtrying the benefit package. Recent reform initiatives have focusedoncontrolling spending andenhancing efficiency, system iscompulsory yet in practice there are significant gaps in populationcoverage and whatisoffered in actions andoutpatient(orambulatory)care to contribute poor healthoutcomes. The socialhealthinsurance The lifeexpectancy ofBulgarianshasimproved thelowest butisstill intheEU. Underdeveloped preventive 1 per 100000population, 2016 Age-standardised mortality rate EUR 2000 EUR 3000 EUR 1000 BG BG BG BG mort l t mort l t Tre t ble 716 773 Highlights Obest Bne drnn Smon EUR 0 2000 Bne drnn 2005 EU EU EU Smon Obest 17 21 22 93 2011 157 BG BG 14 194 15 17 19 20 % 232 % 2017 28 EU

% 748 809 2017 payments alsoadds tohousehold costsforhealthcare. on pharmaceuticals andoutpatientcare. The prevalence ofinformal compared with 15.8%onaverage), andismainly driven by co-payments Out-of-pocket (OOP)spending in2017 was thehighestinEU(46.6% below theEUaverage of9.8%, buthigherthaninneighbouring countries. was thefourthlowest intheEU2017. This represents 8.1%ofGDP, Despite doubling since2005, per capita healthspending, atEUR1311, Health system one infive being overweight orobese. is justbelow theEUaverage, itisa growing problem among children, with but isincreasing among teenage boys. theobesityrateWhile among adults alcohol consumption in2014 was slightly below theEUaverage foradults, (36.4 %among men). Smoking among teenagers isalsocommon. Heavy smoking among adultsisthehighestinEUandstoodat28%2014 challenge. Despiteaslightreduction intobaccoconsumption, therate of Reducing thehigh prevalence ofbehavioural riskfactors poses amajor Risk factors (TB) are alsoan ongoing concern. educational lines. Morbidity from infectiousdiseasessuch astuberculosis are significant disparities inhealthstatusacross gender, and regional system diseasesandcancerare the principal causesofdeath, andthere widened the gap between BulgariaandtheEUaverage. Circulatory 2000 and2017butlarger increases inotherEUMemberStateshave Life expectancy inBulgariaincreased by more thanthree years between Health status % reporting unmet medical needs, 2017 Accessibility EU BG the mainbarrierstoaccessibility. proportion ofthe population, are health insurance forasignificant of OOPspending, andlack of more heavily affected. Highlevels 2008, low-income groups are needs are atthelowest level since Although self-reported unmet %01 0% Hh ncome Countr EU %01 State of Healthin the EU ·Bulgaria ·Country HealthProfile 2019 Countr EU EU Countr All 3% Low ncome 6% have provendifficult. resources away from hospitals reorienting servicedelivery and Efforts toimprove efficiency by base ofsocialhealthinsurance. totherevenuethat contributes shrinking working-agepopulation expenditure as well asthe a heavy reliance on private is challenged by the healthsystem of sustainability The financial Resilience 3

BULGARIA 2 Health in Bulgaria BULGARIA Life expectancy at birth has increased and Romania recorded shorter life expectancy in in Bulgaria but large differences 2000, gains in these countries have outpaced those between men and women persist in Bulgaria. The gain in life expectancy has been greater among women than men, thus widening the While life expectancy in Bulgaria increased from pre-existing gender gap to seven years. Despite this, 71.6 years in 2000 to 74.8 years in 2017, it is the women in Bulgaria have the shortest life expectancy lowest in the EU (Figure 1). Although Latvia, Estonia in the EU (78.4 years), while men have the third lowest (71.4 years).

Figure 1. Bulgaria’s population has the shortest life expectancy in the EU Yers 2017 2000 90 – Gender gap: Bulgaria: 7 years 85 – EU: 5.2 years 834 831 827 827 826 825 824 822 822 821 818 817 817 816 816 814 813 812 811 811 809

80 – 791 784 78 7 78 773 76 758 753 749 748 75 –

70 –

65 – EU Sp n Itl Frnce MltCprusIrelnd Greece Polnd Ltv NorwIcelndSweden Austr F nlndBel um Czech Eston Crot Bul r Portu l Sloven GermnDenmr Slov Hun rL thun Romn Luxembour Netherlnds Un ted n dom Source: Eurostat Database.

Inequalities in life expectancy by Figure 2. Bulgarians with tertiary education have a education level are substantial life expectancy up to seven years longer than those who have not completed secondary education As shown in Figure 2, men with low levels of educational attainment at age 30 live on average 6.9 years less than those with tertiary education, albeit this is a smaller gap than the EU average of 511 7.6 years. For women, the gap is less pronounced – ers 466 455 4.5 years – but slightly greater than the EU average ers ers 386 of 4.1 years. This gap in longevity can be explained, ers

at least partly, by differences in exposure to various risk factors, such as tobacco consumption and poor Lower Higher Lower Higher nutrition.1 educated educated educated educated women women men men Infant mortality has improved but Education gap in life expectancy at age 30: regional disparities persist Bulgaria: 4.5 years Bulgaria: 6.9 years EU21: 4.1 years EU21: 7.6 years Bulgaria achieved significant improvements in infant Note: Data refer to life expectancy at age 30. High education is defined as mortality between 2000 and 2018, more than halving people who have completed a tertiary education (ISCED 5-8) whereas low the rate from 13.3 to 5.8 deaths per 1 000 live births, education is defined as people who have not completed their secondary an outcome at least partly attributable to its National education (ISCED 0-2). Source: Eurostat database (data refer to 2016). Programme on Maternal and Infant Health.

1: As people with higher level of education tend to be of higher socioeconomic status, the education gaps in life expectancy are also related to differences in income and living standards, which may affect both exposure to different risk factors and access to health care.

4 State of Health in the EU · Bulgaria · Country Health Profile 2019 -100 100 % c quintile. with only abouthalfofthoseinthelowest income considered themselves tobein good health, compared four infive ofthoseinthehighestincomequintile income groups inBulgariathantheEU. More than (Figure 4). However, wider disparitiesexistacross in good health, close totheEUaverage of69.7% In 2017, two thirds ofthe population reported being exist bygroupincome in good health, yet disparities stark The majorityofpeoplereport being colorectal andbreast cancer. have alsoincreased inrecent years, in particular smoking (Section3). Mortalityrates from othercancer nearly 12%since2000, in part reflecting thelegacy of related mortality, andthedeathrate hasincreased by Lung cancer was themostfrequent causeofcancer- Source: Eurostat Database. Note: Thesize of thebubbles isproportional to themortality rates in2016. Figure 3. Cardiovascular diseases andcancer account for themajorityof deaths inBulgaria deaths per 100000 inhabitantsin2016(around three numbers ofdeathsinBulgaria, with arate of1100 Circulatory systemdiseasesaccountforthehighest leading causeofdeath inBulgaria Cardiovascular diseasesare the Institute, 2019a). in Pleven (11.3)andRazgrad (10.6)(NationalStatistical and 2.6intheSofia(capital) district, but much higher rates aslow as1.5reported intheSmolyan district However, substantialregional disparities persist, with -50 50 0 hn dne e 2000-16(orner dsese Br Pneumon est cncer Dbetes Chronc obstructvepulmonr dsese Isc 50 hemc hertdsese est Lver dsese Color

er) Lun cncer ectl cncer 100 State of Healthin the EU ·Bulgaria ·Country HealthProfile 2019 150 increased useof hypertension medication. annual check-ups forcardiovascular diseases)and improved early detectionandtreatment (such asfree reduction insome behavioural riskfactorsas well as marked in women thanmenandis partly duetoa than halved since2000. The drop hasbeenmore disease, thesecondhighestcauseofdeath, hasmore (Figure 3). Incontrast, mortality from ischaemic heart stroke was thecauseofaround deaths onefifthofall to stroke (compared with anEUaverage of80). Infact, times theEUaverage of360). Ofthese, 300 were due Source: Eurostat Database, based onEU-SILC (data refer to 2017). incomes are roughly thesame. Note: 1.Theshares for thetotal population andthepopulation on low their healthpositively Figure 4. Two thirds of theBulgarian population rate Unted n dom Luxembour 200 Netherlnds Ae-stndrdsed mortlt rteper100000populton,2016 Low ncome Romn Germn Lthun Denmr Hun r Portu l Sloven Slov Bul r Bel um Norw Sweden Czech Eston Greece Fnlnd Isc Crot Icelnd Austr Polnd Cprus Irelnd Frnce Ltv Mlt Spn Itl hemc hertdsese EU 0 250 % of dults whoreport ben n ood helth Totl populton 20 40 Str 300 oe 60 H h ncome 80 350 100 5

BULGARIA About two fifths of life after age 65 is lived Just over half the people aged 65 and over reported with some health problems or disabilities having at least one chronic disease, a proportion that is slightly below the EU average. However, nearly a

BULGARIA In 2017, Bulgarians aged 65 could expect to live an quarter of the population aged 65 and over reported additional 16.1 years, an increase of two years since severe disabilities that limited their basic activities 2000. However, as is common in other EU countries, of daily living (ADL) such as dressing and showering. a number of years of life after age 65 are spent with This is much higher than the average across the EU some health problems or disabilities. In Bulgaria, this (18 %). is only around seven years on average, substantially less than the average across the EU (Figure 5). While the gender gap in life expectancy at age 65 remains substantial, with Bulgarian men living almost 4 years less than women (14.1 years compared to 17.8), the gap in the number of healthy life years2 is less than 1 year, as women tend to live a greater proportion of their lives with chronic diseases or disabilities.

Figure 5. Half of Bulgarians aged 65 and over have at least one chronic disease

Lfe expectnc t e 65

BulrLfe expectnc t e 65EU Bulr EU

161 7 3 199 10 99 88 ers ers 161 7 3 199 10 99 88 ers ers

Yers wthout Yers wth dsblt dsblt Yers wthout Yers wth dsblt dsblt % of people ed 65+ reportn chronc dseses % of people ed 65+ reportn lmttons n ctvtes of dl lvn (ADL) % of people ed 65+ reportn chronc dseses % of people ed 65+ reportn lmttons Bulr EU25 n ctvtesBulr of dl lvn EU25 (ADL) Bulr EU25 Bulr EU25 17% 20% 23% 18%

49% 17% 46% 20% 23% 18% 34% 49% 46% 34% 77% 82% 34% 34% 77% 82% No chronc One chronc At lest two No lmtton At lest one dsese dsese chronc dseses n ADL lmtton n ADL No chronc One chronc At lest two No lmtton At lest one dsese dsese chronc dseses n ADL lmtton n ADL

Notes: 1. Chronic diseases include heart attack, stroke, diabetes, Parkinson’s disease, Alzheimer’s disease and rheumatoid arthritis or osteoarthritis. 2. Basic activities of daily living include dressing, walking across a room, bathing or showering, eating, getting in or out of bed and using the toilet. Sources: Eurostat Database for life expectancy and healthy life years (data refer to 2017); SHARE survey for other indicators (data refer to 2017).

2: ‘Healthy life years’ measure the number of years that people can expect to live free of disability at different ages.

6 State of Health in the EU · Bulgaria · Country Health Profile 2019 Source: ECDC Surveillance Data average Figure 6. Thenumberof newly reported cases of tuberculosis hasdeclinedbutcontinues to exceed theEU in theEU/EEA(Figure 6). Inaddition, themeasles population compared with 11 per 100000 population double theEU/EEAaverage –21 per 100000 control. In2017, thenotification rate was almost over thelastdecade, theepidemic isnot yet under Although thenumber ofnew TB caseshasdecreased in managing communicable diseases facesimportant still Bulgaria challenges Not f ct on rte for 100000 popult on 120 150 60 90 30 0 2003 2004 2005 2006 2007 2008 State of Healthin the EU ·Bulgaria ·Country HealthProfile 2019 2009 2010 Bulr Section 5.1). ongoing inmonitoringvigilance and vaccination (see million population in2017, thediseaserequires Romania recorded anotification rate of462 per population in2016to23.22017. As neighbouring notification rate jumped from 0.1 permillion 2011 Ltv 2012

2013 L thun 2014 2015 Romn 2016 2017 EU28 7

BULGARIA 3 Risk factors BULGARIA Behavioural risk factors account for Bulgaria has the highest rate of adult smoking, more than half of all deaths and the second highest among teenage girls

It is estimated that 51 % of all deaths in Bulgaria Bulgaria has achieved some progress in tobacco are attributable to behavioral risk factors, compared control in recent years (see Section 5.1), but smoking with 39 % across the EU as a whole (Figure 7). Dietary remains a major public health problem (Figure 8). risks, including low fruit and vegetable intake, and The rate of adult smoking is the highest in the high sugar and salt consumption, were implicated in EU, with more than one in four adults smoking 33 % of all deaths in 2017, the highest proportion in daily in 2014 (and more than one in three men). the EU and almost double that of the EU as a whole Regular smoking among teenagers is also extremely (18 %). Tobacco consumption (including direct and concerning, especially among girls. Some 37 % of second-hand smoking) contributed to an estimated 15- to 16-year-old girls in Bulgaria reported smoking 21 % of all deaths, while around 5 % were attributable daily during the preceding month in 2015, the second to alcohol consumption, and 4 % to low levels of highest rate in the EU after Italy. physical activity (Figure 7).

Figure 7. Dietary risk factors are implicated in one third of all deaths

Detr rss Tobcco Alcohol Bulr 33% Bulr 21% Bulr 5% EU 18% EU 17% EU 6%

Low phscl ctvt Bulr 4% EU 3%

Note: The overall number of deaths related to these risk factors (55 000) is lower than the sum of each taken individually (67 000) because the same death can be attributed to more than one factor. Dietary risks include 14 components, such as low fruit and vegetable consumption and high sugar-sweetened beverage consumption. Source: IHME (2018), Global Health Data Exchange (estimates refer to 2017).

Overweight and obesity rates in children Overweight and obesity levels are becoming a major are a major public health issue problem in children, with one in five now falling into these categories. This is the fourth highest rate in the While the obesity rate among adults in Bulgaria EU, and has increased substantially since 2005-06. In (14 %) was just below the EU average (15 %) in 2014, response, programmes targeted towards school-age the consumption of fruit and vegetables among children promote healthy eating (see Section 5.1). On adults is very low (the second lowest among all EU a positive note, available data indicate that on average countries). Nearly two thirds of the adult population children meet recommended levels of physical do not consume at least one piece of fruit each activity. day, and more than half do not eat vegetables daily. Physical activity among adults is also low, with only 58 % of adults engaging in at least moderate physical activity every week, less than the EU average of 64 % (Figure 8).

8 State of Health in the EU · Bulgaria · Country Health Profile 2019 3: Bingedrinkingisdefinedasconsuming sixormorealcoholicdrinksonasingleoccasion foradults, andfiveormorealcoholicdrinksfor children. (23-24 %). almost thesameregardless ofeducationalattainment exception issmoking, where therate among adults is among those with ahighereducationin2017. The lower educationlevels were obese, compared to11% expectancy. For example, almost14%of people with significantly toinequalitiesinhealthandlife among socially disadvantaged groups contributes or income–andthehigher prevalence ofriskfactors prevalent among people with lower educationand/ Many behavioural riskfactorsinBulgariaare more to healthrisks Socioeconomic inequalitycontributes EU-SILC 2017, EHIS2014 andOECD Health Statistics 2019 for adultsindicators. room for progress inallcountries inallareas. Sources: OECD calculations based onESPAD survey 2015 andHBSCsurvey 2013–14 for children indicators; and Note: Thecloser thedot isto thecentre, thebetter thecountry performs compared to other EUcountries. Nocountry isinthewhite ‘target area’ asthere is Figure 8. Smokingandunhealthy diet are majorpublichealthproblems inBulgaria (also known asbinge drinking) heavy alcoholconsumption atleastonceamonth Approximately oneinsixadults(17.1%)reported boys engage in binge drinking More than halfofBulgaria’s teenage men (26%)than women (9.2%). Moreover, in2015, the EUaverage (20%) yet much more frequent among Frut consumpton (dults) Veetble consumpton (dults) Phscl ctvt (dults) 3 , which islessthan Obest (dults) Select dots +Effect >Trnsform scle 130%

State of Healthin the EU ·Bulgaria ·Country HealthProfile 2019 Smon (chldren) 6 social outcomesinadolescents. consumption, anditseffectsoneducational of accidents andinjuriesrelated toheavy alcohol This isof particular concern given theincreased risk the preceding month, well above theEUaverage. reported atleastoneepisode ofbinge drinking during more thanhalf of 15-to16-year-old boys inBulgaria Overweht ndobest (chldren) Smon (dults) Bne drnn(dults) Bne drnn(chldren)

BULGARIA 4 The health system BULGARIA A single public insurer and its branches budget is 24 % higher than in 2017. As a proportion of currently purchase services GDP, Bulgaria spent 8.1 % on health in 2017, below the EU average of 9.8 % but higher than in neighbouring Bulgaria has a compulsory social health insurance countries (Figure 9). (SHI) scheme, with a small role for Voluntary Health Insurance (VHI). The Ministry of Health is responsible Box 1. Reform initiatives have sought to reduce for regulating and coordinating the health system hospitalBox 1. activityReform initiatives have sought to reduce as well as for licensing a dense network of health hospital activity care providers, including hospitals (Box 1). Within Several reforms have targeted the high density and the SHI, the National Health Insurance Fund (NHIF) activitySeveral of reformshospitals have with targeted the intention the high of density curbing and its regional branches are the core purchasers of relatedand activity spending. of hospitalsMunicipalities with the own intention the majority of health services. In July 2019, the Minister of Health of publiccurbing general related andspending. specialist Municipalities hospitals whoseown the proposed a reform of SHI to allow private insurers to numbersmajority have of public decreased general from and 281 specialist to 234 hospitalssince 2000. compete with the NHIF in offering the public benefit Bedwhose capacity numbers in public have hospitals decreased has from fallen 281 butto 234 private package but such a change is still in the early stages sectorsince beds 2000. continue Bed capacity to rise in (Section public hospitals 5.3). There has was of discussion. Notably, the past few years have been an fallenattempt but to private introduce sector the beds National continue Health to rise Map as marked by challenges to policy implementation and a tool(Section for selective 5.3). There contracting was an attempt between to introducethe NHIF and the rising influence of the national courts in this area. hospitals;the National however, Health implementation Map as a tool forof thisselective aspect of thecontracting legislation between was stopped the NHIF by and the hospitals;courts in 2016. Health spending has increased significantly Newhowever, plans for implementation selective contacting of this aspectwere introduced of the but is still among the lowest in the EU in 2018legislation yet no was significant stopped byprogress the courts has inbeen 2016. achieved New to date.plans However,for selective budget contacting and other were legislation introduced in in In 2017, Bulgaria spent EUR 1 311 per capita (adjusted 20192018 introduced yet no significant stricter licensingprogress hasprocedures been achieved for new for differences in purchasing power) on health, which hospitalsto date. and However, a ban onbudget the NHIFand other contracting legislation with in is the fourth lowest in the EU. Health spending per them.2019 introduced stricter licensing procedures for person more than doubled between 2005 and 2017, new hospitals and a ban on the NHIF contracting with an annual average growth rate of 5.3 % since with them. 2009, outpacing the growth rate of every other EU Member State except Romania (see Section 5.3). Health spending continues to grow: the 2019 NHIF

Figure 9. Health spending per capita is low but consumes a significant share of GDP

Government & compulsor nsurnce Voluntr schemes & household out-of-pocet pments Shre of GDP

EUR PPP per cpt % of GDP 5 000 125

4 000 100

3 000 7 5

2 000 50

1 000 25

0 00 EU Itl Spn Frnce Irelnd Mlt CprusGreece Polnd Ltv Norw AustrSweden Belum IcelndFnlnd Czech Eston BulrCrot Germn Denmr SlovenPortul SlovLthun Hunr Romn Netherlnds Luxembour Unted ndom

Source: OECD Health Statistics 2019 (data refer to 2017).

10 State of Health in the EU · Bulgaria · Country Health Profile 2019 800 600 900 400 EUR PPPpercp t Sources: OECD Health Statistics, 2019; Eurostat Database (data refer to 2017). 3. Includes homecare. Notes: Administration costs are not included; 1.Includes onlytheoutpatient market; 2.Includes curative-rehabilitative care inhospital andother settings; Figure 10. More than40 %of healthexpenditure isspentonpharmaceuticals andmedicaldevices 2018), althoughaccording totheNHIF, the proportion lacked healthinsurance in2017(Ministryof Finance, a totalof719000 people (10.2%ofthe population) estimates from theMinistryofFinanceindicatethat of the population isuninsured. The mostrecent universal healthcoverage, asignificant proportion statesthatthereAlthough SHIlegislation should be health insurance coverage One inevery seven lacks Bulgarians health expenditure in2017. In contrast, VHI accountedforonly 0.5%ofcurrent household spending (Zahariev &Georgieva, 2018). spending onhealth andadd tothe pressure on private estimated tomake upaconsiderable share OOP ofall medicines (seeSection5.2). Informal payments are cost-sharing forarange ofservicesand prescription (including mostdentalandlong-term care), as well as for servicesnotcovered by thebenefit package the EU. The drivers ofOOPexpenditure are payments of healthexpenditure in2017, thehighestshare in Out-of-pocket (OOP) payments represented 46.6% Ministry ofHealthandmunicipalities. revenues are allocated via annual budgetstothe pensioners, the poor, andothers. Othertax-financed state makes for tax-financedcontributions children, are madeby individuals andemployers –andthe the introduction ofSHI in1998. SHIcontributions is alsothelowest level recorded forBulgariasince is thesecondlowest intheEUafterCyprus. This for 52.1%oftotalhealthspending in2017, which Public financing ofthe healthsystemaccounted EU in the Out-of-pocket payments are the highest 200 500 300 700 100 0

spend n

of totl

4 nd med cldev ces

3% Phrmceut cls

567

522

spend n

of totl

34% Inpt ent cre

449

State of Healthin the EU ·Bulgaria ·Country HealthProfile 2019

835 (Council oftheEuropean(Council Union2019;seeSection5.2). ofhealthcareposes seriousconcernsforaccessibility payments, thehighnumber ofuninsured people abroad; EAMA, 2017). Together with highOOP 14 %(afteraccounting forthose who live permanently of residents notcovered by SHIislikely tobearound amounts to2.6%ofhealthspending. care, compared totheEUaverage ofEUR89– which spends around EUR34 per person on preventive EUR 234 per capita in2017. Inabsoluteterms, Bulgaria increased substantially since2010butstoodatonly Spending onambulatory (oroutpatient)care has the significanceofhospitalsectorinBulgaria. care accounted for 34%ofhealthspending, reflecting than theEUaverage (EUR522)(Figure 10). Inpatient terms (EUR567 per person), itisonly slightly higher highest intheEU(over 40%), althoughinabsolute Bulgaria’s spending on pharmaceuticals was the measured asa proportion oftotalexpenditure, of Bulgaria’s current healthexpenditure. When inpatient care togetheraccountedforthree quarters In 2017, pharmaceuticals andmedicaldevices, and absorb the majorityofhealthspending Pharmaceuticals andinpatient care population isageing more rapidly thanin by municipal socialassistance. As theBulgarian care, orinresidential care centres thatare financed few designatedlong-term care bedsininpatient needing residential care are either placed inthe cared forinformally by family members, those benefit package. many While older peopleare Long-term care servicesare excluded from the Few resourcesarededicated to long-term care

spend n

of totl

18% Outpt ent cre

234

858

spend n

of totl

3% Bul r

34 34

0 Prevent on

89 11 EU

BULGARIA many other EU Member States (European and second only to Germany. The average length of Commission-EPC, 2018), accessible and affordable stay was halved between 2000 and 2017, and at 5.3 long-term care will become a key challenge. The days is below the EU average of 7.9 days. Nevertheless,

BULGARIA National Strategy for Long-Term Care (2014) and its inpatient care features a high level of activity, with accompanying action plan for implementation (issued by far the highest rate of hospital discharges (around in 2018) have not yet had any substantial impact. 31 700 per 100 000 population) in the EU in 2017, and almost double the EU average (17 000; see Section 5.3). The numbers of nurses and general Conversely, the number of outpatient contacts in 2017 practitioners are low in Bulgaria was relatively low – 6.1 visits per year per person on average compared to 7.2 in the EU. Bulgaria has a relatively high number of doctors, close to the German rate, but the second lowest density Primary care is sometimes bypassed by patients of nurses in the EU after Greece (Figure 11). In 2016, only 15.5 % of doctors were general practitioners Primary care is provided by GPs, who are independent (GPs), well below the EU average of 27.3 %. This practitioners contracted by the NHIF, operating in is partly due to the late introduction of specialist individual or group practices. Specialised outpatient training in general medicine and the fact that it is activities are delivered mainly by a network of less attractive as a specialty. The rapid ageing of the private specialist practices, centres for diagnostics GP workforce also contributes to low numbers. The and treatment, and diagnostic laboratories. GPs act numbers of midwives, dentists and pharmacists are as gatekeepers and a referral is needed for specialist high relative to their EU averages. However, there are care, diagnostic tests and hospital care. However, marked regional disparities in the distribution of all monthly quotas for patient referrals are in place and health care personnel, posing ongoing challenges for GPs often reach these quotas before the end of the accessibility (Council of the European Union, 2019; see month, meaning that remaining patients either have also Section 5.2). to wait or visit a specialist directly (without a referral) and pay out of pocket (Zahariev & Georgieva, 2018). The health system is very hospital-centred This, in part, may explain why up to a third of all patients, including the uninsured, bypass primary The density of hospital beds in Bulgaria – 7.5 beds per care doctors by calling an ambulance or going directly 1 000 population in 2017 – is higher than the EU average to hospital emergency departments.

Figure 11. The low number of nurses contrasts with that of other health professionals

Prctcn nurses per 1 000 populton 20 Doctors Low Doctors H h Nurses H h Nurses H h 18 NO

FI IS 14 IE DE

12 LU BE NL SE SI D 10 FR EU EU vere 85 MT 8 U HR LT HU RO EE CZ ES PT AT 6 IT PL S LV CY BG 4 EL

2 Doctors Low Doctors H h Nurses Low EU vere 36 Nurses Low 0 2 25 3 35 4 45 5 55 6 65 Prctcn doctors per 1 000 populton

Note: In Portugal and Greece, data refer to all doctors licensed to practise, resulting in a large overestimation (e.g. of around 30 % in Portugal). In Austria and Greece, the number of nurses is underestimated as it only includes those working in hospitals. Source: Eurostat Database (data refer to 2017 or nearest year).

12 State of Health in the EU · Bulgaria · Country Health Profile 2019 Source: Eurostat Database (data refer to 2016). indicators refer to premature mortality (under age75). Thedata are based ontherevised OECD/Eurostat lists. treatable (or amenable)causes isdefined asdeath that can bemainlyavoided through health care interventions, includingscreening andtreatment. Both Note: Preventable mortality isdefined asdeath that can bemainlyavoided through publichealth andprimarypreventive interventions. Mortality from Figure from 12.Mortality both preventable andtreatable causes are highinBulgaria preventable mortality, stroke, ischaemic heartdisease from lung cancer, which accountedfor16%of higher thantheEUaverage of161(Figure 12). Apart stood at232 per 100000 population, substantially In 2016, the preventable mortalityrate inBulgaria Preventable isslowly mortality declining 5.1. 5 Unted ndom Ischemc dseses hert Lun cncer Stroe Performance of thehealthsystem Luxembour Netherlnds Effectiveness Lthun Germn Denmr Romn Hunr Ae-stndrdsed rtes mortlt per100000populton Portul Sloven Slov Bulr Belum Norw Sweden Czech Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Itl Preventble cusesofmortlt EU 0 50 100 Others Accdents (trnsport ndothers) Alcohol-relted dseses 100 110 115 118 121 129 150 133 134 138 139 140 140 141 154 155 158 161 161 161 166 200 184 195 218 250 232 232 244 262 300 310 State of Healthin the EU ·Bulgaria ·Country HealthProfile 2019 325 350 332 336 conditions. scope forimproving diagnosis andtreatment ofthese the EU. This indicatorhighlightstheconsiderable per 100000 population, thefourthhighestrate in 2016, mortalityfrom treatable causes was 194deaths significantlyAlthough ithasfallen since2000, in major drivers ofmortalityfrom treatable causes. all preventable deaths. These conditionsare also and hypertension to41%of togethercontributed Unted ndom Colorectl cncer Ischemc dseses hert Stroe Luxembour Netherlnds Lthun Germn Denmr Romn Hunr Ae-stndrdsed rtes mortlt per100000populton Portul Sloven Slov Bulr Belum Norw Sweden Czech Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Itl EU Tretble cusesofmortlt 0 50 62 62 63 67 67 68 69 71 71 71 76 77 78 80 80 100 87 87 89 90 93 Others Brest cncer Hpertensve dseses 95 128 130 150 140 143 168 176 200 194 203 206 208 250 13

BULGARIA Preventive and health promotion Infectious diseases are still a major challenge policies have had a muted effect Bulgaria continues to have high notification rates

BULGARIA Very high levels of mortality from stroke, for infectious diseases, with TB being of particular cardiovascular diseases and lung cancer are concern (see Section 2). Despite steady decreases and associated with the high prevalence of behavioural targeted attention through the National Programme risk factors (see Sections 2 and 3). Bulgaria earmarks for Prevention and Control of TB (2017-20), the 1 % of excise duties on tobacco and alcohol products notification rate is among the highest in the EU. to fund national primary prevention programmes. Bulgaria also has the second highest notification The National Programme for Prevention of Chronic rate, after Romania, for children under 15 (ECDC & Non-communicable Diseases (2014-20) also highlights WHO Regional Office for Europe, 2019). Compulsory the need to reduce risk factors but the impacts of vaccination against TB and other vaccine-preventable concrete actions are mixed. Legislation to mitigate diseases is being challenged by declining coverage smoking includes bans on smoking in public places rates (Box 2). and on sales to minors, restrictions on tobacco advertising, and warnings and images on cigarette Figure 13. Vaccination rates for children are lower packaging. Nevertheless, little progress has been than recommended levels by WHO achieved in reducing smoking rates, partly due to Bul r EU weak enforcement of health legislation and a lack of information campaigns. Dphther, tetnus, pertusss Amon chldren ed 2

Efforts to tackle the increasing numbers of 92 % 94 % overweight and obese children include the ‘Healthy Kids’ project, which promotes physical activity and balanced nutrition in primary schools, as well as the National Strategy for Physical Education and Mesles Amon chldren ed 2 Sports Development 2012-22. The government also attempted to introduce a tax on foods and drinks high 93 % 94 %

in salt, trans-fat, sugar or caffeine in 2015 but the legislation failed to win the support of parliament.

Heptts B Amon chldren ed 2

Box 2. Despite sanctions, Bulgaria has seen a 85 % 93 % decline in vaccination coverage

Under the Health Act (2004), vaccinations against TB, hepatitis B, diphtheria, tetanus, pertussis and measles are mandatory for children in defined age groups and dispensed free of charge. Vaccination Influenz Amon people ed 65 nd over coverage is monitored at the regional level and provided by GPs or designated offices in Regional 2 % 44 % Health Inspectorates. Despite sanctions, such as fines for non-compliant parents and barriers to enrolling children in public day care, vaccination coverage rates have been declining (Rechel, Note: Data refer to the third dose for diphtheria, tetanus, pertussis and Richardson & McKee, 2018). In 2017, 93 % of hepatitis B, and the first dose for measles. children were vaccinated against measles, and Source: WHO/UNICEF Global Health Observatory Data Repository for children (data refer to 2018); OECD Health Statistics 2019 and Eurostat 92 % against hepatitis B and diphtheria, tetanus Database for people aged 65 and over (data refer to 2018 or nearest year). and pertussis respectively, both of which are below the WHO recommended levels of 95 % (Figure 13).

The influenza vaccination for adults is recommended and paid out of pocket, resulting in the lowest coverage in the EU, with only 2 % of people aged 65 and over being immunised. This is far below the EU average and the 75 % target set by WHO.

14 State of Health in the EU · Bulgaria · Country Health Profile 2019 Source: CONCORD Programme, London Schoolof Hygiene&Tropical Medicine. Note: Data refer to people diagnosed between 2010 and2014. Figure 14. Five-year cancer survival islower thaninmost EU countries available. be avoided altogetherifbetteroutpatientcare were outpatient care, 10 %ofhospitalisationscouldwhile of hospital procedures could beimplemented in the NationalHealthPlanestimatesthatabout20% health servicesandthe primary care sector. Notably, partly duetotheunderdevelopment of preventive very highhospitalisation rates (seeSection4)are quality ofcare have beenslow. Inaddition, Bulgaria’s services inBulgariais poor andimprovements inthe Evidence shows thattheeffectiveness ofhealth quality carehas been slow Progress towards moreeffective and cancer, remain butstill below EUaverages (Figure 14). are increasing forbreast, prostate andcolorectal 24 %incities(Eurostat, 2019). Five-year survival rates having nobreast cancerexamination, compared to States. In2016, half of women inrural areas reported rapidly butremain low compared tootherEUMember check-up with aGP. Screening rates are picking up 2011 for women over 50, inaddition toanannual Biennial breast cancer screening was introduced in improvement inearly detectionandtreatment. below theEUaverage in2016, there isroom for Although overall cancermortalityinBulgaria was cause forconcern Low survival rates from cancerarea Bulr EU26 83% Brest cncer 78 % EU26 87% Prostte cncer Bulr

68 % State of Healthin the EU ·Bulgaria ·Country HealthProfile 2019 established. However, asofmid-2019, nocentre has yet been rehabilitation, long-term care and palliative care. services from screening, diagnostics, treatments, establishment ofcentres offering a wide range of diseases was planned for2016. Itinvolved the model forchildren andchronicwith disabilities example, theimplementation ofanintegrated care care delivery have oftenbeensubjecttodelays. For Efforts toreplace thehospital-centred modelof European Commission, 2019). the humanhealthand veterinary domains(ECDC& professionals andalack ofcoordination between AMR, including limitedknowledge among healthcare anumberstill of gaps and weaknesses intackling Surveillance hastargeted thisissuebutthere are Programme fortheRationalUseof and Antibiotics OfficeforEurope,Regional 2019). The National (up from 35%in 2007(ECDC, 2018;ECDC& WHO showed combinedresistance toseveral antimicrobials Klebsiella pneumoniae bloodstream infections to theBulgarianhealthsystem. In2017, 50%of Antimicrobial resistance (AMR)isamajorconcern Antimicrobial aconcern isstill resistance EU26 60% Colon cncer Bulr 52 % EU26 15% Bulr Lun cncer 8 % 15

BULGARIA 2017 (2.7 %) than in 2008 (16.5 %), although again the 5.2. Accessibility level was much greater among low-income groups There has been a steep reduction than high-income groups (5.5 % compared to 0.5 %). BULGARIA in self-reported unmet needs Cost is the most frequently cited reason for foregoing medical or dental care, followed by distance. Self-reported unmet needs for medical care was 2 % in 2017, the lowest level recorded over the preceding Gaps in social health insurance coverage persist decade, and a decline of 13 percentage points from A lack of SHI coverage creates a major barrier to the level reported in 2008, which was the highest access for a considerable proportion of the population in the EU at the time. On average, Bulgarians now (10 %–14 %, see Section 4). Uninsured individuals have only a slightly higher level of unmet needs for are required to pay directly for medical services medical examination due to the combined reasons of unless they visit an emergency department in a cost, distance or waiting times than the EU average life-threatening situation. This disproportionally (Figure 15). However, the rate is substantially higher affects the long-term unemployed, the Roma among populations on low incomes (5.6 %) than population and those living in disadvantaged regions those on high incomes (0.3 %). There also has been (Box 3). a substantial decline in self-reported unmet needs for dental examination, which was six times lower in

Figure 15. Self-reported unmet needs for medical care is close to the EU average but with a sizeable difference among income groups

% reportn unmet medcl needs Hh ncome Totl populton Low ncome 20

EU Itl Spn Greece Ltv Polnd Irelnd Cprus Frnce Mlt Eston Fnlnd Icelnd BelumBulr Crot SwedenNorw Czech Austr Romn Sloven SlovPortul Lthun DenmrHunr Germn Luxembour Netherlnds Unted ndom Note: Data refer to unmet needs for a medical examination or treatment due to costs, distance to travel or waiting times. Caution is required in comparing the data across countries as there are some variations in the survey instrument used. Source: Eurostat Database, based on EU-SILC (data refer to 2017).

Box 3. Several vulnerable groups do not have health coverage

The long-term unemployed are thought to account not covered. This issue particularly affects Roma for a quarter of the total uninsured population. SHI people and irregular migrants. According to estimates, coverage is lost if the insured person fails to pay as many as one third of the Roma population do more than three monthly contributions over a period not have a valid ID card. Together, these vulnerable of three years. Another quarter of the total uninsured groups make up around 16 % of the total population population comprises people who can afford SHI in the regions of Burgas, Varna, and Dobrich (Institute contributions but choose not to pay. The most for Market Economics, 2018). Although additional frequently stated reason is distrust in SHI. These funds are transferred to the NHIF to cover some abstainers tend to renew their SHI coverage only if preventive activities and acute care for the uninsured, their health deteriorates (and are then required to evidence on unmet needs suggests that some of settle 60 months’ worth of SHI contributions to be these individuals would forgo care more often or only reinstated). Citizens without a valid ID card are also seek care once their health has deteriorated.

16 State of Health in the EU · Bulgaria · Country Health Profile 2019 n obtnn helthservces Percente of poorer households experencn dffcultes Bulr Source: Eurostat Database (data refer to 2017). Note: Onlyhouseholdsbelow 60% of median equivalised income are shown, aggregated by highandmoderate burden inobtaining care. Figure 17. Low-income households are disproportionately impacted by thecosts of illhealth low-income households the proportion of people some difficultyinobtaining medicinesin2017. Among Bulgarians experienceddifficultyand54.8% reported needs inrecent years, survey datashow that 32.6 %of Despite thedecreasing level ofself-reported unmet Sources: OECD Health Statistics 2019 (data refer to 2017). Figure 16. Bulgaria hasthehighest out-of-pocket spendingintheEU excluded services islong-term care anddental dedicated funds. The mostimportant categoryof children are covered by thestatebudgetorother organ transplantation, andtreatment abroad for health care, renal dialysis, in vitro fertilisation, specialised medicalservices. Emergency care, mental hospital diagnostics and treatment; andhighly medical andbasicdentalcare; laboratory services; currently includes primary andspecialisedoutpatient to equalaccesshealthcare. The benefit package on the grounds thatitunderminedcitizens’rights part was overturned by theConstitutionalCourt package intoabasic part andacomplementary In 2015, anattempt toreorganise thebenefit overruled by the ConstitutionalCourt An attempt to split the benefit package was Overll shreof helth spendn Medcl cre Dentl cre Medcnes 466% OOP 0 Dstrbuton ofOOPspendn b tpeofctvtes 20 Others 31% Dentl cre 16% Phrmceutcls 327% medcl cr Outptent Inptent 41% e 50% State of Healthin the EU ·Bulgaria ·Country HealthProfile 2019 40 Not OOP higher fordentalcare (Figure 17). and 39.2%somedifficulty. This proportion was even the EU–57.9%reported ahigh degree ofdifficulty reporting difficulties was thehighest recorded in reimbursed by theNHIF. for pharmaceuticals andmedicaldevices thatare care isrestricted. Inaddition, there isa positive list countries in2017. consumption in Bulgaria, thelargest share among EU long-term care, accountedfor6.3%offinalhousehold (Figure 16). Overall, OOPmedicalspending, excluding followed by outpatientcare andinpatient care account fortheoverwhelming ofOOPspending, bulk devices, through direct payments andco-payments, times theEUaverage. Pharmaceuticalsandmedical spending inthe EUin2017, which was almostthree At 46.6%, Bulgariareported thehighestshare ofOOP especially forpharmaceuticals Affordability continues to deteriorate, OOP EU Overll shreof helth spendn 60 158% OOP Dstrbuton ofOOPspendn b tpeofctvtes 80 Others 33% Dentl cre 25% Phrmceutcls 55% medcl cr Outptent Inptent 14% EU e 31% Bulr 100 Inptent Outptent medclcre phrmceutcls Dentl cre Others 17

BULGARIA Exemption mechanisms are not sufficient A lack of GPs hinders the availability to alleviate the burden of co-payments of primary care

BULGARIA High OOP payments are driven by co-payments for Although Bulgaria has a comparatively high density the majority of covered services; direct payments for of health professionals (except for nurses), their excluded services, such as most dental care for adults; distribution is uneven. The situation of doctors is a and informal payments. The monthly quotas which case in point (Figure 18). The small number of GPs are limit GP referrals also provide incentives for patients unequally distributed across the country, favouring to seek specialist care without a referral, where they urban and more affluent districts, which leads to pay the full cost of treatment (see Section 4). considerable shortages in others. Disadvantaged areas – often remote rural areas or small towns – are Exemptions from co-payments are in place for perceived as unattractive to settle in, and entail high children, pregnant women (including those workloads as patient lists are longer (more than 2 700 uninsured), patients suffering from chronic diseases, patients per GP in regions such as Kardzhali). The cancer patients, medical professionals, those with ageing of the workforce and retirement of GPs are incomes below a certain threshold, and some other also ongoing challenges. Strategies such as increasing groups. Pensioners pay reduced co-payments per the numbers of medical and nursing graduates, as visit, with the NHIF paying the difference. However, well as financial incentives to settle in underserved there is no additional protection for pharmaceutical areas, have been implemented. In 2016, Bulgaria co-payments. While some 10 % of the Bulgarian registered the highest number of graduates in both population are also enrolled in VHI to mitigate OOP professions since 2002. However, the continuing trend spending, VHI plays only a marginal role among of emigration and urbanisation is likely to decrease vulnerable groups. the number of available health professionals in areas of need.

Figure 18. The regional distribution of doctors is heavily skewed towards more affluent districts

Slstr Vdn 345 291 Rzrd Dobrch Ruse 341 Montn 271 375 Vrts Pleven 287 273 161 Shumen Vrn Vel o Trnovo Trovshte 333 200 Lovech 313 336 262 Gbrovo 258 Sof Sof Pern (cptl) 254 Slven 349 196 331 Burs Str Zor 305 Ymbol ustendl Plovdv 241 343 282 Pzrdzh 195 282

Hs ovo Bloevrd 339 Populton per one ph scn, 2018 335 Smoln 335 rdzhl < 250 386 250 - 320

> 320 Ntonl vere 233

Note: The national average is calculated by taking into account the total number of doctors including those attached to other offices and includes practitioners working in individual or group practices under a contract with the NHIF in more than one district. Source: National Statistical Institute, 2019.

18 State of Health in the EU · Bulgaria · Country Health Profile 2019 -6% 4: Resilience refers4: Resilience tohealthsystems’capacityadapteffectively tochanging environments, suddenshocks orcrises. private increased sectorfacilities by 78times. hospitals actually decreased 1.7timesbutthosein time period thenumber ofhospitalisationsin public other EU countries (Figure 20). However, over the same hospital bedssince2005isatodds with thetrend in the same period. Overall, therisein number of and bednumbers increased by afactorof36over the number of private hospitalsincreased six-fold and 32.6%respectively between 2000and2016, public hospitalsandbeds, which decreased by 16.7% sector expansion:incontrast with thenumber of admission rate intheEU. This ismainly dueto private to grow. Bulgariahasby farthehighesthospital specialist outpatientcare, inpatient care continues Despite policy objectives tostrengthen primary and carecontinuesHospital to grow Source: OECD Health Statistics, 2019; Eurostat Database. Figure 19. Public spendingonhealthhasgenerally outpaced GDPgrowth since 2008 continuewill to grow. budget plans suggest that public spending onhealth tool forhealthexpenditure andthecurrent national (Figure 19). The NHIFbudgetisthemain planning on healthhasoutpacedGDP growth since2008 2012 and2015, theannual growth in public spending times theEUaverage of1.5%. With theexception of annum between 2009and2017, more thanthree spending grew onaverage by more than5.3% per Although thetrend has notbeenconsistent, health outpacing growth otherEUMemberStates. inall significantly since2000, from albeit alow base, Current health expenditure inBulgariahasincreased than inotherEUMember States Health expenditurehas grown faster 5.3. 12% 15% -3% 9% Annul chne nrel terms 0% 6% 3% Resilience 2006 2007 4

2008 2009 2010 State of Healthin the EU ·Bulgaria ·Country HealthProfile 2019 2011 across theEU. performed inoutpatientsettings, compared with 84% since 2010. In2016, 37%ofcataract surgeries were ofdaybut theutilisation bedshasbeenincreasing care provided inday surgery settings isnotavailable Extensive informationaboutthe proportion ofall use ofday surgery andreduce inpatient stays. hasalsoattemptedlegislation tostimulate greater be implemented (seeBox 1inSection4). Recent policy initiatives, of notall which managed to many factorsandhasbeentargeted by several The over-utilisation ofinpatient care isrooted in and clearly show thereliance onhospitalcare. treated cost-effectively inambulatorycare settings, EU countries. These are conditionsthatcanbe for heartfailure, diabetes, andasthmaamong all In 2015, Bulgariahadthehighestadmissionrates (European Commission-EPC, 2018). to grow by 0.2%ofGDPbetween 2016and2070 same time, public spending onhealthisstill projected revenue baseoftheNHIFin years tocome. At the to decline, leading tofewer tothe contributors the proportion of people of working age continuewill continued emigration. Unlessthistrend isreversed, or over) andshrinking duetoanatural decline and ageing (currently onefifthofinhabitantsare 65 years 2019). Added tothis, Bulgaria’s population isboth low public funding oftheEuropean (Council Union, private spending, which needstocompensate for expenditure hasbeen largely financedthrough stable at8%of wages, theriseinBulgaria’s health As earmarked toSHIhave contributions remained constrain healthsystemfunding a declining working-age population Over-reliance onprivate spending and 2012 2013 2014 GDP 2015 Publc spendnonhelth 2016 2017 19

BULGARIA Figure 20. The increase in hospital bed numbers has been driven mainly by private sector expansion

Bulr Beds ALOS EU Beds ALOS

BULGARIA Beds per 1 000 populton ALOS (ds) 8 14

7 12 6 10 5 8 4

3 6

2 4 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Note: ALOS: average length of stay. Source: Eurostat Database.

Public hospitals experience chronic deficits Bulgaria has introduced health technology assessment for pharmaceutical reimbursement High debt levels in public hospitals are an enduring problem that is often addressed with stopgap Given the very high level of spending on measures, such as periodic injections of funds, yet pharmaceuticals (see Section 4), the introduction not resolved. Bulgaria funds its hospitals using case of HTA in 2015 was an important milestone in payments defined through clinical pathways. The making cost-effectiveness a key criterion for the method of calculating these payments is meant reimbursement of medicines. Initially assigned to a to reflect the cost of associated medical activities, special commission at the National Centre of Public auxiliary services and post-discharge consultations Health and Analysis, HTA is applied to medicines not for each pathway but in practice they reflect the previously included in the Positive Drug List. In 2019, NHIF’s ability to pay rather than the real costs of responsibility for HTA was transferred to the National hospital services. There is an imbalance in the Council for Pricing and Reimbursement of Medicinal funding of different pathways, with some being Products, which oversees both the process of deciding overfunded while others are underfunded, creating which medicines are included in the positive list, and an adverse incentive for hospitals to overuse some their reimbursement level. Only generic medicines clinical pathways. Overall, the underfunding of and products containing active substances that are clinical pathways is seen as one of the drivers of well established are exempt from HTA. persistent hospital deficits (Zahariev & Georgieva, 2018).

20 State of Health in the EU · Bulgaria · Country Health Profile 2019 5: The currentrole ofthis committeeisnotclear. was usedtohelpintroduce HTA. consultative body chaired by theMinisterof Health, example, inthe past the ‘Partnership forHealth’, a system could beakey toolfor building consensus. For building among key stakeholders inthehealth Constitutional Courtsafterbeing challenged. Coalition example, were stoppedby the Administrative and at increasing efficiency inthehospitalsector, for in policymaking. reformAlmost all initiatives aimed years andunderminescontinuity andconsistency a majorobstacle toimplementing reforms inrecent Frequent turnover of political leadershiphasbeen steering change. National Strategy canbeaneffective instrumentfor System. However, itremains tobeseen whether the implementing theNationalHealthInformation and infanthealth), andlong-term goals such as national programmes (e.g. TB andimproving maternal encompasses many disease-andaction-specific health statusindicators with EUaverages. Italso the convergence ofBulgaria’s main population The NationalHealthStrategy 2020aimstodrive strategies but implementation isslow Governance isorganised through national positions more attractive ascareers (Box 4). of delivered care, orhow tomake GPandnursing not aninstrumentintendedtoaddress thequality workforce planning anddistribution. However, itis National HealthMap could now beusedasatoolfor based methodology was confirmedin2018andthe (e.g. inmaternalandinfanthealth). The needs- population healthneedsandnational goals inhealth levels were calculatedtaking intoaccountregional and hospitalcare by district. These minimum minimum number of providers neededinambulatory National HealthMap was developed the thatdetailed and nurses in primary care isensured. In2015, a be iftheavailabilitypossible ofGPs, specialists outpatient care (where clinically appropriate) will Successfully shifting more hospitalservicesto planninghealth workforce A National steer HealthMapcould 5

State of Healthin the EU ·Bulgaria ·Country HealthProfile 2019 will beneeded. health professionals, including doctors andnurses, term, discussions onhow to change theskillmixof for outpatient andinpatient care. Inthelonger include detailed minimum staffing requirements developed for allmedicalspecialties andwill strategy. Asafirst step, standards are to be salaries, anddevelop along-term development of Healthto improve working conditions, raise low salarylevels. Thenurses asked theMinistry (BAPZG), many nurses have two jobs because of Association of Professionals for Healthcare who have remained. According to theBulgarian overburdened theworkload of those nurses and themigration of mostly young nurses has The average age of nurses andmidwives is55 working conditions of thenursing workforce. Association inMarch 2019 shedlightonthe Protests by members of theBulgarian Nursing workforce problems Box 4. There hasbeensome progress intackling 21

BULGARIA 6 Key findings BULGARIA • Despite significant improvement in life • Out-of-pocket spending is a key barrier to expectancy since 2000, Bulgaria records the access: making up 47 % of current health lowest life expectancy in the EU. The high expenditure, Bulgaria reports the highest prevalence of risk factors such as smoking, share in the EU. Pharmaceuticals account alcohol consumption and poor diet contribute for the overwhelming proportion of private to high mortality rates from stroke, ischaemic expenditure on health, followed by spending heart disease and lung cancer. on outpatient care. Informal payments, in the form of ‘gratuities’ to doctors, are estimated to • The implementation of primary prevention make up a considerable share of out-of-pocket and health promotion activities is relatively payments. While reported unmet needs for weak, as reflected by the high rate of both medical and dental care have dropped preventable mortality. Similarly, mortality steeply over the last decade, there are large from treatable causes in Bulgaria is the fourth differences in unmet needs between high- and highest in the EU, indicating that the health low-income groups – with cost remaining the system is generally failing to treat patients most cited reason for foregoing care. effectively and in a timely manner. About one fifth of hospital procedures could be • The biggest challenge for accessibility of implemented in outpatient care, while a tenth health care is the significant proportion of of hospitalisations and related procedures the population (around 14 %) not covered could be avoided altogether if better by health insurance. The gap in population outpatient care were available. coverage disproportionately affects the long-term unemployed, the Roma population • The underdevelopment of primary and and those living in disadvantaged areas. The preventive care partly explains Bulgaria’s high uneven distribution of health care facilities, levels of hospital activity and hospitalisation health professionals and services across the rates, but strong growth in the number of country also hampers accessibility, with rural hospital beds in urban areas and in the private areas often underserved while larger cities sector also reinforces the concentration have an oversupply of services. on inpatient care. Reforms have sought to contain hospital activity and strengthen • Shortages of health professionals, especially outpatient care, including initiatives such as nurses and general practitioners, are the National Health Map, medical guidelines, hindering the development of primary care and a stricter licensing regime. However, and the delivery of services in underserved some major reforms have been challenged by areas. Strategies to increase the number stakeholders and overturned by the courts. of medical and nursing graduates and to improve salaries and working conditions have • Although health spending in Bulgaria is still been launched to address these challenges. relatively low compared to other EU Member States, it has increased steadily over the last 15 years. However, the rise in health expenditure has been mainly fuelled through out-of-pocket spending. In fact, the health system now relies almost equally on private spending and public sources as its sources of revenue, with the share of public financing (52 %) having declined in recent years. This trend raises equity concerns over the affordability of health care, particularly for people on lower incomes.

22 State of Health in the EU · Bulgaria · Country Health Profile 2019 Key sources

Dimova A et al. (2018), Bulgaria: Health system review. OECD, EU (2018), Health at a Glance: Europe 2018: Health Systems in Transition, 20(4):1–256. State of Health in the EU Cycle. OECD Publishing, Paris, https://www.oecd.org/health/health-at-a-glance- europe-23056088.htm

References

EAMA (2017), Annual report on condition and overall Institute for Market Economics (2018), Regional Profiles, activity of the health insurance in Republic of Bulgaria Indicators of Development 2017. Institute for Market for 2016. Executive Agency Medical Audit, Ministry of Economics, Sofia. Health, Sofia. Ministry of Finance of the Republic of Bulgaria (2019), ECDC (2018), Surveillance of antimicrobial resistance Written answer to parliamentary question No. 01-00- in Europe 2017 – Annual report of the European 133. Sofia on 27 March 2019. Sofia. Antimicrobial Resistance Surveillance Network (EARS- Net) 2017. European Centre for Disease Prevention and National Statistical Institute (2019a), Crude death and Control, Stockholm. infant mortality rates by place of residence, statistical regions, districts and sex in 2018, Sofia. ECDC, European Commission (2019), Country visit to Bulgaria to discuss policies relating to antimicrobial National Statistical Institute (2019b), Geographical resistance. Final joint report. European Centre for representation of data on physicians in health Disease Prevention and Control, Stockholm. establishments by medical speciality, statistical regions and districts as of 31.12.2018, Sofia. ECDC, WHO Regional Office for Europe (2019), Tuberculosis monitoring and surveillance in Europe Rechel B, Richardson E, McKee M, eds. (2018), The 2019 – 2017 data. WHO Regional Office for Europe, organization and delivery of vaccination services in the Copenhagen. European Union. European Observatory on Health Systems and Policies and European Commission, Council of the European Union (2019), Council Brussels, http://www.euro.who.int/__data/assets/pdf_ Recommendation on the 2019 National Reform file/0008/386684/vaccination-report-eng.pdf?ua=1 Programme of Bulgaria, http://data.consilium.europa.eu/ doc/document/ST-10155-2019-INIT/en/pdf Zahariev B, Georgieva L (2018), ESPN Thematic Report: Inequalities in access to healthcare. Bulgaria 2018. European Commission (DG ECFIN)-EPC (AWG) European Commission, Brussels. (2018), The 2018 Ageing Report – Economic and budgetary projections for the EU Member States (2016- 2070). Institutional Paper 079. May 2018. European Commission, Brussels.

Country abbreviations

Austria AT Denmark DK Hungary HU Luxembourg LU Romania RO Belgium BE Estonia EE Iceland IS Malta MT Slovakia SK Bulgaria BG Finland FI Ireland IE Netherlands NL Slovenia SI Croatia HR France FR Italy IT Norway NO Spain ES Cyprus CY Germany DE Latvia LV Poland PL Sweden SE Czechia CZ Greece EL Lithuania LT Portugal PT United Kingdom UK

State of Health in the EU · Bulgaria · Country Health Profile 2019 23 State of Health in the EU Country Health Profile 2019

The Country Health Profiles are an important step in Each country profile provides a short synthesis of: the European Commission’s ongoing State of Health in the EU cycle of knowledge brokering, produced with the ·· health status in the country financial assistance of the European Union. The profiles ·· the determinants of health, focussing on behavioural are the result of joint work between the Organisation risk factors for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and ·· the organisation of the health system Policies, in cooperation with the European Commission. ·· the effectiveness, accessibility and resilience of the The concise, policy-relevant profiles are based on health system a transparent, consistent methodology, using both quantitative and qualitative data, yet flexibly adapted The Commission is complementing the key findings of to the context of each EU/EEA country. The aim is these country profiles with a Companion Report. to create a means for mutual learning and voluntary For more information see: ec.europa.eu/health/state exchange that can be used by policymakers and policy influencers alike.

Please cite this publication as: OECD/European Observatory on Health Systems and Policies (2019), Bulgaria: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.

ISBN 9789264383685 (PDF) Series: State of Health in the EU SSN 25227041 (online)