Svetlana Spassova, MD
Ministry of Health, Bulgaria
Chisinau 07.11.2008
WHO's health system performance
framework
The Health System
in Bulgaria
Revenue collection
HNIF: obligatory population-wide health insurance (6%);
MoH: budget transfers (4,5% of GDP)
Private health insurance companies: voluntary (personal)
health insurance (<10% of HC services market);
OPP
Pooling
NHIF; MoH; private health insurance companies
Purchasing
NHIF – for health insured persons, based on solidarity;
MoH – for uninsured (emergency, birth assistance, hospital
psychiatric service, blood and blood products,
transplantations, certain therapies and pharmaceuticals )
Private health insurers: additional services (extended
package)
Provision
Medical establishments: both private and on contract with
purchasers
Addressing inequalities
in Bulgaria
Addressing the particular health needs of:
- Uninsured people;
- People with low income;
- Disabled people;
- Vulnerable groups: children, youth, elderly;
- Minorities;
- People, suffering from specific diseases.
Addressing inequalities:
Stewardship
 Legislative provisions: The Law on Health and secondary
by-law guarantee access to certain healthcare services,
regardless of insurance status;
 The National Health Strategy: putting the issue of
addressing inequalities on the political agenda;
 National
strategies
and
programs
targeting
disadvantaged groups: focus on information, disease
prevention, provision of services and treatment;
 The EU-Pre-accession instruments (the PHAREprogram) and the Structural funds
Addressing inequalities:
Investment and training
 Availability of qualified human resources- specialization
system financed by the state;
 Investments in infrastructure and facilities – state
financed investment policy provided by MoH, projects
financed under the pre-accession and Structural funds;
municipal budgets
 Access
to
pharmaceuticals
–
legislation
on
pharmaceuticals and medical devices; control of prices
of prescription drugs linked to external and internal
reference and inflation; positive drug list
Addressing inequalities:
Service delivery
 State budget financed access to emergency healthcare,
midwifery care, organ transplantations and follow up
treatment, central procurement of pharmaceuticals for
cancer diseases, rare disease, blood disorders, transplants
and dialysis; immunization and vaccines, neonatal
screening of genetic diseases; access to national, regional
and community programs, transportation, mobile
structures and outreach programs.
 National programs, targeting:
- disadvantaged groups: minorities, people with mental
disorders, people with rare diseases, etc.
- diseases, representing significant socio-economic burden:
cancer, tuberculosis, HIV/ AIDS, etc.
Addressing inequalities:
Financing
National budget spending on:
- health services for uninsured;
- health services for specific vulnerable groups;
- national, regional and communal programs.
- infrastructure
External funding:
- EU fund spending on specific projects, targeting
minorities or diseases, affecting predominantly
vulnerable groups.
- The Global Fund to fight AIDS, tuberculosis and malaria
- infrastructure, regional development, strengthening of
human resources and administrative capacity;
Strengthening health system performance and challenges
Improving health in equitable way requires:
 Functions of the health system, related to reforms
 Reform plans, oriented towards goals
 Overall goals, split into specific objectives
 Measurable
intermediate objectives,
achievement of national objectives
leading
to
Addressing inequalities:
Challenges
• Defining and implementing reforms and investments,
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
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aimed at those most in need of care;
Balancing competing demands and setting clear policy
priorities
Creating awareness in order to prevent conflicts between
different members of society
Developing programs, that deliver added value and have
defined measurable outcomes
Ensuring the availability of qualified health force; creating
incentives for medical professionals
Developing PPP
Addressing inequalities:
Challenges
 Financial restrictions require prioritizing
 Reducing financial barriers which hinder access to
needed care
 Ensuring continuity: a stable flow of resources
 Reaching the disadvantaged people; monitoring the
responsiveness of services
 Evaluating the impact of service delivery strategies.
Measuring Outcomes:
Conclusions
Measures aimed at addressing inequalities strengthen
health system performance, if resulting in
 Better health throughout the entire population;
 Responsiveness of the system to specific needs and
vulnerabilities;
 Sufficient funding and optimal redistribution so as to
enable universal access to health services.
Bulgaria
 Thank you for your attention!
Svetlana Spassova, MD
National Health Policy Director,
Ministry of Health - Bulgaria
sspassova@mh.government.bg