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26 March 2024 | Country Update
Expanding entitlement to prophylactic services -
29 March 2023 | Policy Analysis
A National Map of Long-Term Health Needs will guide health system investments -
01 January 2022 | Policy Analysis
Expanding prophylaxis and specialized obstetric care coverage -
01 January 2021 | Country Update
Inclusion of new services in the National Health Insurance Fund’s benefit package -
16 July 2020 | Country Update
Legislative changes allow nurses and midwives to run stand-alone practices
5.3. Primary / ambulatory care
The Health Care Establishments Act (1999) stipulates the separation of outpatient and inpatient care and determines the nomenclature for different types of health care establishments in Bulgaria. Ambulatory care consists of general and specialized care provided by GPs and specialists respectively and includes a wide variety of providers for both primary and specialized outpatient services, such as GPs, specialist practices, medical centres, laboratories and nursing homes.
Primary care and a large part of the specialized ambulatory care operate mainly in the private sector. There are also ambulatory health care establishments owned by the municipalities and some owned by public hospitals, but they are independent legal entities.
Generally, ambulatory care in Bulgaria is provided by outpatient health care establishments. The only exception being psychiatric hospitals and hospitals owned by the Ministries of Defence, Transport, Informational Technology and Communications, Internal Affairs and Justice, and the CoM can sign contracts with the NHIF for outpatient primary and specialized care.
Primary care
Primary care in Bulgaria is provided by GPs, who are independent practitioners contracted by the NHIF but privately operating their medical practices. There are two types of practices for primary care: individual and group practices. A primary care practice may employ a nurse or other health care professionals. Bulgarian citizens are free to choose their health care provider both for primary and specialized care. Patients are entitled to switch GPs twice per year.
In 2016, approximately 14.9% of all physicians in Bulgaria worked in primary care (NSI, 2017h); consequently, the GP to population ratio is relatively low (0.62 per 1000 population) in comparison with the EU average (see section 4.2.1 Health workforce trends). More worryingly, this ratio is deteriorating and has fallen by almost five percentage points since 2006.
A referral is also needed for diagnostic tests. Children and pregnant women have direct access to paediatricians and gynaecologists, respectively. There is a limited number of patient referrals available to each GP. The number of referrals is predefined on a quarterly basis by the RHIF according to the GP’s patient list, patient specifics (for example, chronic diseases, age) and the performance of the previous months. Up to a third of all patients (including the uninsured) bypass primary care physicians by calling an ambulance or going directly to hospital emergency departments (see section 5.5 Emergency care).
GPs provide basic examinations, diagnostics and treatment, provide consultations and are responsible for prescribing medications from the PDL. They also provide family planning training, preventive activities (immunization), health promotion and health education. Some GP services unrelated to health care provision (for example for a work competence permit, or a document of competence to drive a motor vehicle) are paid for by the patients. The primary care practices are required to display a list of fees and payments in a visible place within the facility.
Since 2010, the number of GPs in Bulgaria has been decreasing (Table4.3). In 2017, 4287 GPs provided primary care, which averages one GP per 1656 citizens. Individual practices prevailed (3476 or 81.1%), whereas 18.9% of GPs worked in a total of only 811 group practices (NHIF, 2017c).
Table4.3
The number of GPs varies significantly between districts in the country. These variations cause inequitable access to health services, particularly for individuals in rural areas. In 2016, the average number of insured persons per GP differed widely across the country – from 1216 persons per GP in the Pleven district to 2404 in the Razgrad district (Fig5.3). In general, access to primary care services varies between urban and rural areas, with residents in remote rural areas facing considerable challenges because of shortage of GPs, a poor infrastructure and geographical distances. Some specific measures have been implemented – financial incentives for primary care physicians who serve rural and remote areas defined as a monthly allowance for the GP practice. These allowances are specified in the NFC by settlements and vary according to the remoteness of the practice from other health care establishments, difficult accessibility due to infrastructure, diffusion of the practice (ambulatory serving two or more settlements), served population and environmental pollution. Shortages due to physician ageing are becoming also a worrying trend, especially in rural areas (see section 4.2 Human resources). As a result, GPs often have to provide services to patients from different villages within a radius of several kilometres.
Fig5.3
There are no official data on quality of primary care. The most common infringements of the NFC in primary care, as identified by RHIF inspections, are related to the delivery of preventive services, provision of dispanserization services, violation of working times and of requirements for medical equipment (NHIF, 2016).
In 2015, the analysis in the concept “Objectives for Health 2020” concluded that the development of primary care continues to be a major challenge. This is due to the limited profile of activities and tasks, lack of incentives for teamwork, limited recognition, weak connection with secondary care and inadequate funding (MoH, 2015b).
Specialized ambulatory care
Specialized outpatient activities at the secondary care level are delivered by a network of specialist practices, centres for diagnostics and treatment, and diagnostic laboratories. The provision of specialized ambulatory care also includes services provided by mental health centres, comprehensive cancer centres, centres for dermato-venereal diseases, and centres for comprehensive service of children with disabilities and chronic diseases. Specialized outpatient facilities may be registered as:
- individual or group practices for specialized medical care in a certain medical specialty;
- medical and medico-dental centres with at least three physicians/dentists who are specialists in different medical/dental fields;
- diagnostic-consultative centres consisting of at least 10 physicians in various specialties, as well as laboratory and imaging sections; and
- stand-alone medical laboratories, consisting of two types: (1) medical-diagnostic laboratories performing laboratory tests and analyses as well as image diagnostics and (2) medical-technical laboratories producing specific medical devices (for example, orthodontic laboratories).
The medical, medico-dental and diagnostic-consultative centres may open units where physician assistants, nurses or midwives perform nursing care independently.
Diagnostic-consultative centres are owned mainly by municipalities and are regulated by the respective municipal council. The remaining specialized ambulatory care providers mostly follow the private-practice model. The specialized outpatient facilities are registered under the Commercial Act. Patients have the right to free choice of a specialist.
Similar to primary care, individual practices for specialized ambulatory care are more common, but their number has been decreasing, by almost 40% since 2010. In contrast, the number of medical centres, medico-dental centres and stand-alone laboratories has increased significantly compared with 2010 (Table5.3). Many specialists share time between their practice and working at inpatient health care facilities.
Table5.3
Most specialists in ambulatory care have a contract with the NHIF. In 2017, 3224 outpatient facilities concluded contracts on the delivery of specialized ambulatory care covered by the NHIF (NHIF, 2017e). The benefit package of specialized health services includes primary and secondary examinations, preventive check-ups, dispensary observation, rehabilitation activities, highly specialized medical activities and expert assessment of temporary disability if the patient’s condition requires a longer sick leave and is consequently covered by SHI.
In 2016, a person covered by SHI made an estimated 0.77 primary and 0.31 secondary visits to outpatient specialists. The number of secondary consultations has been increasing and, in 2016, there were 40–41 secondary visits for every 100 primary consultations (NHIF, 2016).
Among specialists, surgeons, paediatricians, obstetricians, cardiologists and neurologists are the most plentiful (NSI, 2017g). There is a shortage in some specialties such as clinical toxicology, medical parasitology, communicable diseases and allergology. According to the NCPHA, capacity of outpatient care is insufficiently developed, leading to unequal access for the population to medical care, especially in remote areas (NCPHA, 2015a). The distribution of specialists varies regionally with significant imbalances between districts.
Fig5.4 shows average outpatient contacts per person within the WHO European Region in 2014. With 5.9 outpatient contacts per person in 2014, Bulgaria is well below the average of newer Member States (7.54 in 2014), and also below the EU28 annual average of 7.03 per person (WHO, 2018). These data refer exclusively to primary and specialized care outpatient contacts. On the other hand, the estimated number of consultations per physician was only 1480 in 2014, which is among the lowest in the EU (OECD/EU, 2016).
Fig5.4
Amendments in the MoH’s ordinance on prophylactic examinations and dispanserization services broadened the age-specific population groups’ entitled to certain prophylactic services as of January 2024. Dispanserization services are a complex set of medical, diagnostic and prophylactic services that are usually provided for chronically ill patients (diagnoses are specified by an ordinance) and include regular check-ups and diagnostic tests, medical surveillance, and long-lasting and acute treatment.
- The age after which women are entitled to a prophylactic mammography once at every two years has been reduced from 50 to 45 years old. In addition, women above 69 years old have been granted the right to prophylactic mammography once every three years.
- Similarly, younger men (45–49 years old) received entitlement to prophylactic prostate-specific antigen test and the frequency of these tests was increased from once every two years to once every year for the entire entitled group (≥ 45). Previously, only men 50 years and older were eligible.
- Other changes include expansion of the scope of laboratory tests for prophylactic purposes for the entire population in Bulgaria.
All services are part of the routine yearly prophylactic examinations included in the NHIF’s benefit package and paid though its budget.
References
At the end of 2022, the Council of Ministers in Bulgaria adopted the National Map of Long-Term Health Needs. The National Map aligns with the priorities and policies outlined in the National Health Strategy 2030 as well as the reforms envisaged in the National Recovery and Resilience Plan.
A shortage of general practitioners (GP), oversupply of acute hospital beds, and undersupply of long-term care beds, as well as regional disparities in workforce undermine access to outpatient care in more rural regions in Bulgaria. The objective of the National Map is to ensure that future health care investments will contribute to a more equitable and sustainable regional development with improved access to care.
The National Map was developed using the National Health Map methodology and a second methodology jointly developed by the PUB HUB Croatia project team from the Medical University of Zagreb, the European Commission, and representatives from Bulgaria, Croatia, and Slovenia. It maps out and assesses the provision of health services in Bulgaria and identifies long-term needs at the regional and district levels.
In this way, the map is intended as an evidence-based planning tool for interventions and investments in the health system, considering population needs for health services and the existing health infrastructure at the national, regional, and district level.
Through an analysis of health system resources at the regional level and outlining the development potential and the shortfalls of each region, the Map has found that primary care facilities, including GP and nursing professional practices, should be established in underserved areas. Furthermore, the analyses highlight other pressing concerns requiring policy interventions and investments. These include enhancing the capacity for diagnostics and treatment of cerebrovascular diseases and the establishment of highly specialized stroke facilities throughout the country with the capacity for advanced diagnostics, interventional treatment of cerebrovascular diseases, and rehabilitation of stroke patients. The development of the National Platform for Medical Diagnostics is an additional priority, which would provide medical specialists with direct access to up-to-date medical information on socially significant diseases and remote outpatient units with opportunities to interact with specialists and hospital facilities.
Based on these findings and its articulated priorities, the adoption of the National Map of Long-Term Health Needs could significantly increase health expenditures and support the reorganisation of care delivery in Bulgaria to address the most pressing challenges in the health system and better match the differential and evolving needs of the population. However, the National Map of Long-Term Health Needs must enhance transparency in planning and implementation of health reforms.
References
In 2022, the Ministry of Health (MoH) took further steps to extend coverage of the NHIF benefits and obstetric care for uninsured women covered by the MoH. The MoH changed two ordinances expanding the prophylaxis benefit package and the package of obstetric care and medical diagnostics. Together, these ordinances aim to strengthen prophylaxis and care delivered to pregnant women at the primary and secondary care levels. Bulgaria has a higher maternal mortality ratio than the European Union average at 10 deaths per 100 000 live births versus 6 in 2017.
The first ordinance, amended in June 2022, regulates prophylactic check-ups and medical examinations and aims to improve the opportunities for early diagnosis among children, adults, and pregnant women, specifically. It expands the services in the prophylaxis benefit package to include diagnostic tests for children 7 to 18 years old; two additional ultrasound checks-up for pregnant women; an ultrasound examination of fetal morphology in addition to the biochemical screening; a hepatitis C test during pregnancy; and new diagnostic tests for people above 18 years of age.
The second ordinance – on the provision of obstetric care to uninsured women – strives to improve access to specialized outpatient and inpatient care for formally uninsured pregnant women by increasing the number of obstetric check-ups for pregnant uninsured women that is covered by the MoH's budget to four during pregnancy. The package has been further extended to include additional diagnostic tests. The ordinance was amended in August 2022 after broad public discussions and stakeholders’ advocacy involvement. The change will enter into force from 1 January 2023. Expanding the coverage of the obstetric services provided to those women outside the scope of mandatory health insurance has the potential to significantly improve maternal and newborn health outcomes.
References
Dimova A, Rohova M, Koeva S, Atanasova E, Koeva-Dimitrova L, Kostadinova T, Spranger A, Polin K (2022), Bulgaria: Health System Summary, 2022. WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, Copenhagen.
https://data.worldbank.org/indicator/SH.STA.MMRT?locations=EU
Ordinance on prophylactic check-ups: https://www.lex.bg/en/laws/ldoc/2136933195
Amendments in the MoH’s ordinance on the NHIF’s benefit package extended the list of services covered by the social health insurance system in 2021.
In May 2021, a new ambulatory procedure was included in the basic benefit package to cover specialized and highly specialized immunological tests for diagnosis of primary immune deficiencies. In addition, a new clinical pathway for physical therapy, rehabilitation and care of COVID-19 patients after active hospital treatment was introduced.
Another significant change is the inclusion of services intended to improve and protect newborn and children’s health, including home-based health services for newborns up to 14 days after hospital discharge performed by nurses, mid-wives, and physicians’ assistants in October 2021.
References
Individual or group practice can be established by doctors' assistants, nurses, midwives and/or rehabilitation therapists who have at least three years experience in the respective field. The registration will be carried out by the Executive Agency for Medical Supervision.