A shortage of healthcare workers, socioeconomic inequalities in access to care, and significant differences between rural and urban areas are among the challenges Bulgaria faces today. TrendSanità discussed these issues in depth with Antoniya Dimova, professor at the Department of Health Economics and Management and Dean of the Faculty of Public Health at the Medical University of Varna. Her main scientific interests and publications concern health systems and policies and quality management of care. The professor is actively involved in the Health Systems and Policy Monitor Network (HSPM) of the European Observatory on Health Systems and Policies and is a member of the financial protection expert network of the WHO Barcelona Office for health systems financing.
The Bulgarian Healthcare System
Both preventable and treatable mortality rates in Bulgaria are among the highest in Europe
On January 1, 2007, Bulgaria officially joined the European Union, and on April 3, 2024, it officially entered, albeit partially at the moment, the world’s largest free movement area, Schengen. This milestone marks a turning point for the country, especially following updates to the Schengen Borders Code after the COVID-19 pandemic. This reform aims to establish a new legal framework for measures applicable at external borders in case of a health crisis to ensure a coordinated and effective response to future health emergencies.
«The Bulgarian health insurance system was established between 1998 and 1999. Health policy priorities are determined by the Council of Ministers and the Ministry of Health, and social health insurance is administered by a single entity: the National Health Insurance Fund (NHIF)», says Professor Antoniya Dimova, continuing, «The Ministry of Health oversees the health system, public health protection, and health control. At the regional level, there are 28 Regional Health Inspectorates and regional branches of the NHIF. The latter finances medical services and medications through contracts with healthcare providers».
Short Waiting Times and High Density of Doctors
At the European level, Bulgarian healthcare, at a crossroads between public and private, has achieved good results in terms of services offered, especially in recent years. «Compared to EU countries, Bulgaria is one of the countries with the best results regarding waiting times. The density of doctors is relatively high, slightly above the EU average. In Bulgaria, health services are provided by a mixed network of public and private entities. General practitioners act as a bridge to specialist care, whether public or private. Bulgaria has seen an increase in private hospital services in recent decades, with a high percentage of hospital admissions. However, the country’s long-term care capacity remains limited», explains Dimova. «Over the years, there has been a notable decrease in the percentage of people reporting unmet healthcare needs in Bulgaria. The latest available data suggest that unmet needs for medical and dental care are slightly below the EU average. This improvement is mainly attributed to increased service coverage and the fact that people perceive better personal health. However, it should be noted that there is still significant economic inequality among people who cannot access the healthcare and dental services they need, and this gap is growing over time».
Financial Vulnerability and Shortage of Healthcare Personnel
Despite the progress and points of excellence analyzed so far, Dimova cannot help but declare some of the weaknesses of the Bulgarian healthcare system. «The 2022 WHO Barcelona Office report on financial protection in Bulgaria provided solid evidence of financial protection weakness, reflecting the strong dependence on out-of-pocket payments to finance the healthcare system (34% in 2021). The incidence of so-called “catastrophic” expenditures – defined by the WHO as healthcare expenses exceeding 40% of a household’s “capacity to pay” after subsistence costs – has grown over time (from an average of 17% in 2005 to 19% in 2018). This increase was particularly significant among the poorest two quintiles of the population, and occurred mainly in rural areas, small towns, and suburbs compared to cities, and among older households compared to younger ones. In the poorest quintile, the incidence of catastrophic expenditures increased from 51% in 2005 to 64% in 2018».
Reluctantly, the professor points out: «The Bulgarian healthcare system relies heavily on out-of-pocket payments, primarily due to the inability to meet healthcare needs because of financial issues, and this is one of the main causes of inequity in the country. Furthermore, despite the presence of well-trained medical professionals and equipped healthcare facilities, both preventable and treatable mortality rates in Bulgaria are among the highest in Europe, suggesting the system’s inability to ensure consistent quality over time and for the entire population».
Delving into the issue of financial accessibility, especially for vulnerable population groups, Dimova emphasizes: «Access is problematic both geographically and financially. The use of healthcare services varies from district to district, reflecting an uneven distribution of healthcare workers and socioeconomic inequalities in access to care. For example, the number of people covered by NHIF registered with a general practitioner varies from just over 1,000 in some areas to over 2,500 in others, and this gap is increasing. Imbalances are also observed in the distribution of specialists, with a high concentration in university centers and a significant shortage in small towns and rural areas. The financial burden of healthcare spending is a serious obstacle to accessing healthcare services, primarily for the poorest part of the population, the uninsured, and other vulnerable groups».
In Bulgaria, the differences related to income and place of residence are more marked than the average of other European Union countries
A recent study developed by the research group led by Professor Maria Rahova, with the participation of Dimova, conducted at the Department of Health Economics and Management at the Medical University of Varna, evaluated the performance of the Bulgarian healthcare system at the end of 2023. «The results show that there are significant differences in health status indicators between people with the lowest and highest incomes, between those with primary and higher education, and between residents of large cities and villages. In Bulgaria, income and residence-related differences are more pronounced than the average in other EU countries. This means that socioeconomic factors have an even stronger impact on the health of vulnerable people in our country. Financial protection issues are reflected in the following indicators: impoverishing healthcare expenses, catastrophic healthcare expenses, and lack of access to healthcare services due to financial problems. In some cases, these problems can occur simultaneously. As a result, people with lower incomes are the most affected…» Dimova concludes.
Financial Sustainability and Future Challenges
«The biggest challenge for the future remains the resilience of health systems. The most significant obstacle is the large and growing global shortage of healthcare workers. For Bulgaria, in particular, the labor shortage could be addressed through policies aimed at improving the functioning of the healthcare system and managing circular migration». The topic of healthcare services resilience is very dear to Antoniya Dimova, who recognizes the great challenge for the future of healthcare services that affects all countries, some more than others. A topic closely linked to resilience is inevitably that of financial sustainability, which has been severely tested over the years, especially during the pandemic crisis.
«Financial sustainability of healthcare systems is a problem in almost all European countries, especially in times of crisis, which we have all experienced in recent years, starting with the COVID-19 pandemic. In Bulgaria, in particular, despite substantial growth in healthcare spending after the introduction of social health insurance, the system continues to suffer from a lack of economic resources. Although the constant and significant increase does not translate into an improvement in the population’s health status or the stability of the financial system, the misuse of money seems to be the biggest problem underlying the lack of financial resources. Most measures aimed at the financial sustainability of the healthcare system in Bulgaria are focused on increasing public health spending, containing costs, particularly for drugs, and strengthening control over public spending. Little is done to increase efficiency. The shift of some hospital services towards outpatient care in recent years is a positive step in this direction».
Looking to the future, to a more united Europe committed to improving the quality, efficiency, and equity of healthcare services, promoting greater collaboration and coordination among member countries is essential, and this is what Professor Dimova hopes for: «National governments are responsible for the organization, financing, and delivery of healthcare services. The European Commission’s recommendations on how to improve the performance and resilience of healthcare systems would be crucial, especially for countries that need to make progress. Since 2017, the European Commission has started publishing national health profiles on the state of health in the EU, developed by the OECD and the European Observatory on Health Systems and Policies, which I believe is a step in this direction. Universal health coverage and equity in healthcare are common goals that could be addressed at the European level through country-specific recommendations. Additionally, the collection of clinical and health data at the European level is of fundamental importance for progress in the field of health and care in all territories, and I believe that EU institutions could implement this process in the near future».
