2012年-世界发展银行全球_Bulgaria_Health_Sector_Diagnosis___Policy_Note_28页_4mb

Summary and Key Recommendations of Bulgaria Health Sector Diagnosis

Core Content

This policy note provides an in-depth analysis of Bulgaria's health sector, highlighting the challenges and opportunities for reform. It updates a 2009 document and outlines key areas for improvement, including hospital rationalization, strengthening outpatient care, and reforming pharmaceutical policies. The document emphasizes the need for strategic leadership and systemic changes to improve health outcomes and align the system with EU standards.

Main Issues and Way Forward

1. Rationalizing the Hospital Sector

• Challenge: Bulgaria has the highest number of acute care beds per capita among New Member States (NMS), indicating an over-reliance on hospital-based care.
• Inefficiencies: The NHIF contracts with all new entrants in the hospital market, leading to fragmentation and inefficiency.
• Current Measures:
  • Introduction of minimum standards for hospital services to reduce the number of services offered.
  • Implementation of individual hospital caps to stop volume escalation.
  • Delays in introducing DRG-based payments, which could improve transparency and cost control.
• Recommendations:
  • Implement a technically-driven hospital rationalization plan to consolidate service delivery.
  • Support this with genuinely selective contracting and strategic investments.
  • Encourage the merging of facilities into autonomous, financially accountable networks.
  • Introduce DRG-based payments alongside expenditure caps to maintain incentives for cost control.
  • Generate, collect, use, and publicize information on quality to support rationalization efforts.
  • Strengthen quality assurance mechanisms.

2. Strengthening Outpatient Care

• Challenge: Outpatient care is underdeveloped, receiving only 12% of health expenditure in 2008, compared to 25–30% in EU-15 countries.
• Performance: Primary care is underutilized, with only 70% of medical contacts resolved at this level, compared to the EU-15 average of 80%.
• Payment System: The current system is based mainly on capitation without performance-related elements, limiting the incentive for effective outpatient care.
• Recommendations:
  • Strengthen the capacity of primary care professionals to manage chronic diseases.
  • Introduce pay-for-performance elements with a focus on non-communicable diseases (NCDs).
  • Implement additional cross-sectoral measures to combat risk factors for NCDs, such as tobacco control.

3. Pharmaceutical Policies

• Challenge: Out-of-pocket spending on pharmaceuticals is very high, representing over 70% of household health expenditure.
• Issues:
  • Suboptimal use of generic medicines due to lack of prescribing requirements and substitution rights.
  • Inappropriate prescribing influenced by pharmaceutical marketing.
  • Health Technology Assessment (HTA) processes are not used to determine drug reimbursement.
• Recommendations:
  • Conduct a complete and transparent audit of the Positive Drug List (PDL).
  • Review public purchasing methods and develop a strategy to improve transparency in pharmaceutical management.
  • Ensure the process is supported by independent experts to minimize influence from interest groups.
  • Develop and implement policies to encourage and monitor the rational use of medicines, including generics.

Key Findings

Health Status

• Bulgaria's life expectancy at birth is 73.4 years, significantly lower than the EU-27 average of 80 years.
• The burden of non-communicable diseases (NCDs), especially cardiovascular diseases, is particularly high in Bulgaria.
• Bulgaria has a higher standardized death rate for circulatory diseases (611 per 100,000) compared to the EU-27 average (234 per 100,000).
• Cancer death rates are similar to the EU-27 average (172 per 100,000), but higher than in some EU-15 countries.
• Smoking prevalence is high (around 40%), contributing to the burden of NCDs and cancer.
• Obesity rates are relatively low (around 11%) compared to other EU countries.

Coverage and Access

• Preventive services are underutilized, with coverage rates significantly lower than in other EU countries.
• Bulgaria has one of the lowest rates of cervical cancer screening (18%) and mammography (10%) among EU countries.
• Influenza immunization coverage is also very low (less than 5%).

Perceptions

• Patient satisfaction with the health system is among the lowest in the EU.
• In 2009, only 28% of Bulgarians rated the system as "good" or higher, the second-lowest in the EU.
• Unmet need for medical consultation remains higher than in other EU countries, with cost being a major barrier.
• Corruption is perceived as widespread in the public health sector, with 65% of Bulgarians believing it exists, slightly higher than the EU-12 average.

Health Expenditure

• Total health expenditure in Bulgaria is around 7% of GDP, comparable to other NMS.
• Public health expenditure is 3.7% of GDP, lower than the EU-15 average.
• Out-of-pocket (OOP) spending is disproportionately high, reflecting limited financial protection.

Additional Priorities for the Mid-Term

• Address socio-economic and geographic inequalities in health outcomes.
• Improve access to care for the Roma population, which has lower health outcomes and access to services.
• Strengthen long-term care (LTC) systems, particularly for the aging population.
• Enhance data collection and use for decision-making in health policy.

Conclusion

Bulgaria's health system requires urgent reforms to address inefficiencies, improve financial protection, and enhance the delivery of outpatient and preventive services. The three key areas—hospitals, outpatient care, and pharmaceuticals—are interlinked and need coordinated action. The policy note underscores the importance of strong leadership, transparency, and performance-based incentives to achieve better health outcomes and meet the needs of an aging and increasingly diverse population.