• The World Bank recommends: the NHIF should enter into contracts with hospitals selectively

    June 1, 2015

    The current healthcare system financing methods in Bulgaria have put more people at risk of poverty, was noted in the World Bank report of May 12, 2015, which performed a systematic analysis of our country. It discussed the major problems of our healthcare and made a few recommendations.


    According to the report, about 8% of GDP in 2012 in Bulgaria was spent on healthcare. In comparison with the countries of the region, the total healthcare cost in Bulgaria was above the average, and the public expenditure was around the average for the region. The problem was that the direct personal payments (DPP) represented 47% of the total costs. Statistics showed that in 2000 they were 20%. In regard to this indicator Bulgaria is currently far from meeting the criterion of the WHO for adequate financial protection, which sets a ceiling of 15-20% for DPP as total health expenditure share. Moreover, over 4% of the population in Bulgaria is impoverished every year because of the DPP. In 2013, 3/4 of the DPP was spent on medicines that are not well covered by the state health insurance system.

    The World Bank experts also identified as a serious problem that the financial protection provided by the healthcare system was undermined because about 7-12% of the Bulgarians who did not live permanently abroad, were uninsured. The vast majority of them were inoperative vulnerable people with a low socio-economic status.

    The healthcare system in Bulgaria was not effective because it was too oriented to expensive residential care, with non-optimal use of more economical preventive and primary care services, believed the experts. According to the report, the coverage of most preventive services in Bulgaria was much less than in other EU countries, except Romania. Bulgarians also had fewer contacts with doctors providing primary care services and specialist physicians, compared to citizens in the other EU countries. Meanwhile, the number of hospitalizations per capita had jumped by 65% ​​for the period 2000-2010, while hospitalizations in other countries had either remained at the same level or had decreased. In 2011 the level was so high that practically one in four Bulgarians had been hospitalized.

    The report also mentioned that our hospital system was very fragmented. The hospital density was 4.6 hospitals per 100 000 people compared with an average of 2.7 for the EU. Many hospitals had very few patients, which was highly inefficient. The three busiest hospitals discharged more than 95 patients a day, but 103 establishments in the lower section of the list together accounted for only 5% of hospital stays. That meant that approximately one in three hospitals in Bulgaria discharged not more than five patients a day. That fragmentation lead to resource duplication among institutions and prevented the application of economies of the scale that were required in modern healthcare, indicated the document. According to the World Bank experts, that interfered with the proper orientation of the necessary investments.


    One of the main recommendations of the World Bank was for Bulgaria to reorganize its hospital system. They advised the NHIF to purchase services selectively, i.e. it should be able to decide with which hospitals to enter into contracts. In order to support that process, information on the care services quality had to be generated, collected and published, and the hospital payment systems had to be reformed. There might be a need of reforming emergency care, in order to improve the consistent provision of care and the access to it, emphasized the report.


    The report also recommended improving the efficiency of medicine purchases. The World Bank noted that the current medicines pricing methods and the selection of those to be reimbursed provided almost no guarantee for the balance “price-quality”. The policies at that time did not encourage generic medicines market competition, but a lot of the prices on both – patent and of non-proprietary medicines – were unfavorable in comparison with the countries with much higher paying capacity. “Some expensive medicines that contribute to the rapid growth of costs are not likely to be cost effective in Bulgaria and should be subject to price (re)negotiation, severe use restrictions, and in some cases – removal from the list. If Bulgaria is able to promote greater competition in the non-proprietary medicines market, together with measures to meet demands and reasonable prescription, this could improve medicine costs effectiveness significantly,” said the report.

    The experts also recommended strengthening the stationary care alternatives. According to them, the specialists in primary care needed greater capacity to manage the prevailing set of diseases and to coordinate the care for their patients. “In particular, permanent medical education should be implemented effectively and attractively. Regulations and incentives should be adjusted so that the chronic disease management would be extended through primary care. Payment systems and accountability mechanisms would also need to be adapted for all provider types (primary, outpatient, emergency and residential care) to ensure the treatment of more patients on the proper level of care,” was also written in the report.