Bulgaria has a mixed public–private health care financing system. Health care is financed from compulsory SHI contributions, taxes, OOP payments, VHI premiums, corporate payments, donations and external funding. Following the introduction of SHI in the late 1990s, total health expenditure as a percentage of GDP increased steadily and stood at 8.2% in 2015. Except for Slovenia, Bulgaria spent more on health as a percentage of GDP than all new EU Member States. Although both public and private health expenditure contributed to the increase of total health expenditures, the growth rate of private expenditure outpaced that of public spending. Private expenditure on health – mainly OOP payments – has grown from 39.1% in 2000 to 48.9% of total expenditure in 2015 and constitutes the largest source of financing in Bulgaria. Comparing only OOP expenditure, Bulgaria records the largest share among all EU countries with 47.7% of total health expenditure in 2015. This poses a financial burden on the population, especially so for pharmaceutical care, which accounts for approximately two thirds of overall OOP expenditure. Corporate payments are ranked second in private health expenditure, whereas VHI only plays a marginal role, contributing less than 1% to Bulgarian health financing.
The role of public financing has decreased steadily since the transition period to an SHI system in the late 1990s and accounted for slightly more than half of total health expenditure in 2015. Public financing mainly stems from SHI contributions managed through the NHIF, which made up 41.9% of total health expenditure. General government expenditure continued to decrease and stood at 9.2% of total health expenditure in 2015. Roughly 60% of SHI revenues are mobilized through income-related SHI contributions paid by employees and employers. In addition, SHI contributions paid by the state on behalf of 11 population groups such as children and pensioners make up for approximately one third of the total contribution revenue but cover two thirds of the total population. By law, all Bulgarian citizens are compulsorily insured with the NHIF; however, a significant share of up to 12% of the population is de facto uninsured.
The NHIF has acted as the main purchaser of health services since 1998. Relations between the NHIF and health care providers are based on a contract model. The NHIF and professional associations of physicians and dentists sign the NFC, which is intended to regulate the formal and operational procedures of the compulsory health insurance system. The benefit package includes primary and specialized outpatient medical care, outpatient diagnostic services, dental care, and inpatient services that are regulated by clinical pathways and procedures. Providers are mainly remunerated prospectively for the services they provide to the population on a fee-for-service and per capita basis. Public health services, emergency care and state psychiatric hospitals are funded by global budgets of the MoH. Approximately half of current health expenditure is spent for curative and rehabilitation services. Despite reform efforts to contain overall hospital activity through decreasing the number of public hospitals and beds, introduction of ceilings to inpatient procedures, and introduction of clinical and ambulatory procedures, inpatient care accounts for the largest share of curative and rehabilitative care expenditure.
The references cited throughout this chapter can be found in the published PDF file of Health System Review for Bulgaria 2018.