Bulgaria: health system review

Abstract

The Health Systems in Transition (‎‎‎HiT)‎‎‎ profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. Health reforms in Bulgaria started at the beginning of 1990s and were aimed to make the Bulgarian health system more efficient and responsive to patients’ needs, by improving quality of service and delivery of care. The establishment of the National Health Insurance Fund and a basic benefits package defined the services covered by the public sector and earmarked the revenue collection for health care allowing for more sustainability of the health care budget. However, a financing system solely based on contributions failed to provide enough funding for the system. Approximately one million people opting out of universal coverage meant that there were fewer contributors than beneficiaries and this led to potential adverse effects on the balance of the National Health Insurance Fund. Legalization of private practice had a positive impact on access to health services and the resulting competitiveness between health care providers acted as an incentive for higher quality of service provision. However, commercialization of health care and a stronger focus on market relationships had an adverse impact on the social function of health care and gave rise to lack of motivation among providers. The restructuring of primary care and the introduction of GPs as gatekeepers to specialized care allowed for cost-containment but led to a discussion of whether such policies dilute the principles of free provision and access to health care for the population. The restructuring of inpatient health care financing and provision was followed by the introduction of clinical pathways. This created better incentives for improving both quality and effectiveness of service provision. However, the actual cost of implementing clinical pathways for the hospital is higher than the price reimbursed by the National Health Insurance Fund, which causes financial instability in the inpatient sector.