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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.

The members of the Parliamentary Health Committee approved the restoration of the arbitration committees. This happened during a meeting last Thursday, when the amendments to the Health Insurance Act were adopted at second reading. The final vote on the Act in the plenary chamber lies ahead.

The MPs debated whether Regional Health Inspection representatives should be included in arbitration committees. Most of them advocated the idea that this would affect the balance in decision making. According to them, the number of the Regional Health Insurance Fund representatives has to be equal to that of the professional organizations representatives. The heads of the Bulgarian Medical Association, the Bulgarian Dental Association, the Bulgarian Organization of Healthcare Professionals, and the Bulgarian Pharmaceutical Union, who had attended the meeting, supported the view that there should be parity. In the end, the lawmakers decided to eliminate that part of the bill which guaranteed committees to include Regional Health Inspection representatives.

The Ministry of Health even suggested the number of Regional Health Inspections position openings to be reduced from 2877 to 2502 position openings. The draft amendments to the Rules of the Regional Health Inspections Department have been published on the website of the Ministry of Health for public comment.

After motivated proposals made by the Directors of the Regional Health Inspections, it was determined that state inspections should reduce the total amount of position openings by 375 position openings, and the rest are to be distributed between the inspections.

The MPs rejected a proposal to amend the Health Insurance Act, which regulated the amount of fines imposed by the NHIF for various violations. They accepted the viewpoint of the Ministry of Health and the professional organizations that the Health Insurance Act did not need such a text. The President of the Dental Association Dr. Borislav Milanov noted that since the National Framework Contract negotiated prices and volumes, it was appropriate it would also determine the fines. Deputy Minister of Health Dr. Boyko Penkov had similar views that sanctions should be regulated in the National Framework Contract. In the long run, the MPs voted that the fines are to be negotiated among the NHIF, the Bulgarian Medical Association and the Bulgarian Dental Association in the Framework Contract.

Meanwhile, the MPs did not accept the proposal of Dr. Emil Raynov from the Bulgarian Socialist Party to transfer to the NHIF budget a sum of BGN 1.4 billion. He motivated his idea by reminding that the amount taken from the reserve of the NHIV by the preceding government of the party GERB had to be recovered. The proposal was supported only by the opposition lawmakers.

Nebivolol is a third generation beta-adrenergic receptor blocker with vasodilating properties. It has the highest affinity for beta-1 receptors when compared to other beta-blockers (BB). Due to the leverage effect on endothelial nitric oxide synthase (eNOS) and its antioxidant activity, nebivolol significantly improves the endothelial function.

Endothelial function and dysfunction

Endothelium modulates the function of blood vessels and provides structural integrity. Endothelial cells synthesize nitric oxide (NO), which has powerful anti sclerosis activity and, along with prostacyclin, inhibits platelet aggregation, the neutrophil adhesion to endothelial cells, and the expression of inflammatory molecules. At a higher concentration NO inhibits smooth muscle cell proliferation.

The endothelial dysfunction treatment should aim not only to increase the NO level, but also to reduce the free radicals which neutralize it – superoxide and peroxynitrite.
It has been established that medicaments which are limited to the delivery of NO – like organic nitrates – due to the stimulation of the production of peroxynitrite worsen rather than improve the endothelial function.

The ideal drug for endothelial dysfunction treatment should stimulate the NO synthesis and simultaneously reduce the oxidative stress in the vessel wall.

Nebivolol is a third generation BB with vasodilating properties, thanks to its direct stimulating effect on eNOS. The mechanisms of action include a negative chronotropic effect, the inhibition of sympathetic stimuli from the brain vasomotor centers, the inhibition of peripheral alpha-1 adrenoceptors, the inhibition of renin activity and a decrease in peripheral vascular resistance.

The  high selectivity for β1- versus β2-adrenergic receptors explains the limited effects of nebivolol on airway reactivity and insulin sensitivity, as well as the lesser negative inotropic action of the drug in patients with heart failure (HF).

As in other BB, nebivolol has important electrophysiological properties, such as increasing the threshold of ventricular fibrillation, and reducing the dispersion of the QT interval and P wave, which is associated with risk reduction for ventricular arrhythmia and atrial fibrillation.

The indications for the application of nebivolol include arterial hypertension (AH), chronic heart failure (HF) and ischemic heart disease (IHD).

Arterial Hypertension
The efficacy and safety of nebivolol in doses of 5 and 10 mg in patients with hypertension grades I and ΙΙ have been demonstrated in numerous clinical studies. The response of systolic blood pressure (BP) to nebivolol is similar to the use of other BB and calcium channel blockers (CCBs), and is more pronounced than that of angiotensin-converting enzyme inhibitors.
The effect of the drug on diastolic blood pressure is not so pronounced, contributing to the safety of nebivolol.

Heart Failure

Large randomized trials and meta-analyzes have demonstrated that BB reduce morbidity and mortality in patients with chronic heart failure by about 30%. This effect is due to the decrease of adrenergic stimulation, modulating the balance between sympathetic and parasympathetic activity, influencing the heart rate and variability, and improving the myocardial function.

It is important to note that while other BB act mainly by decreasing the stroke volume, nebivolol and carvedilol cause peripheral vasodilatation, maintain the stroke volume, the cardiac output, and the chronotropic response during exercise.

Moreover, compared with bisoprolol, nebivolol and carvedilol do not lead to an increase of the pulmonary capillary wedge pressure (but rather improve it).
The average age of the patients included in trials with the use of BB in heart failure was 60 years. In this respect, SENIORS was an exception, as it included patients over the age of 70. It established a 14% reduction in all-cause mortality and improvement of the cardiac dimensions and function when nebivolol was used, as compared to placebo.

Ischemic heart disease

There is evidence that in comparison with atenolol, nebivolol more effectively improves exercise tolerance and time to onset of chest pain during ECG stress tests.
Moreover, nebivolol and carvedilol increase the coronary flow reserve in patients with Ischemic heart disease and non-ischemic cardiomyopathy more effectively compared to other BB, which is probably associated with an increased ischemic threshold.
Nebivolol is contraindicated in patients with severe bradycardia, atrioventricular block above the second degree, cardiogenic shock, decompensated heart failure and severe liver diseases failure.

Tolerability and safety profile

In patients with bronchial asthma and chronic obstructive pulmonary disease, the higher selectivity of nebivolol to beta-1 receptors compared to other BB results in better tolerance.
For the same reason nebivolol has no adverse effects on the libido and the sexual function. On the contrary, there is evidence that the drug improved erectile dysfunction, which could significantly increase the compliance of patients. Due to its vasodilatory effect (and unlike older beta-1 selective BB), nebivolol does not lead to the deterioration of insulin sensitivity and an increased risk of type 2 diabetes (neutral metabolic profile). It has no adverse effects on lipid parameters.

The incidence of hypertension in Bulgaria is above the European average, reported doctors from the Bulgarian Hypertension League in connection with the 17^th of May, when the world observed World Day of the Sick. According to experts, the country’s hypertension rate is around 55% while the average for Europe is 30-45%. Physicians’ data indicates that only 37% of the patients with this disease are treated adequately.

Arterial hypertension (AH) is identified as the leading global risk for mortality, responsible for 9.4 million deaths worldwide. Every third person in the world suffers from high blood pressure, and only one of the three is treated effectively.

Hypertension significantly increases the risk of micro and macrovascular complications, doubling the total mortality and the incidence of stroke, tripling the likelihood of coronary heart disease (CHD) and accelerating the progression of diabetic nephropathy, retinopathy and neuropathy.

The adequate treatment of AH prolongs life. The decrease in systolic blood pressure by 12 mm/Hg for 10 years saves from death 1 in 11 treated patients and decreases the frequency of stroke by 35-40%, of myocardial infarction – by 20-25%, and of heart failure – by 50%.

Arterial hypertension is often part of a combination of anthropometric and metabolic disorders, including abdominal obesity, dyslipidemia (abnormal lipid profile), high blood sugar, etc., defined as “metabolic syndrome” (MetS). Obesity is the risk factor №1 for hypertension. Therefore, the Bulgarian Hypertension League has selected the metabolic syndrome components to be the focus in the national information campaign dedicated to the World Hypertension Day 2015, which passed under the motto “Healthy weight – healthy blood pressure.”

Already in 2002, the World Health Organization alerted that the global epidemic cardiovascular disease increase is associated with an increase in the number of overweight and obese people. Over 1 billion people worldwide are overweight, 400 million of them – are obese. Obesity is a growing problem among adolescents. It is reported that 1 in 6 children in the world is overweight, and in the US – 1 of 3.

According to the Bulgarian Society of Endocrinology, 34.93% of the population in Bulgaria is obese, and 38.95% – overweight. This means that every second Bulgarian man (45%) and every third Bulgarian woman (32.4%) between 30-60 years is overweight. More alarming is the fact that 40% of Bulgarian children (21.9% of the boys and 17.7% of the girls of 5-17 years) are also overweight or obese. This identifies not only an aesthetic problem, but a problem of poor health, of risk for a number of serious diseases that threaten life quality and life expectancy. The close link between some cardiovascular diseases and obesity defines the group of “obesity-related cardiovascular diseases.” These are arterial hypertension, atherosclerosis, heart failure, atrial fibrillation, stroke, sleep apnea, and peripheral venous disease.

Being overweight is one of the strongest predictors of hypertension. Hypertension is about 6 times more frequent in obese people than in those with normal weight. The incidence of hypertension increases with the unidirectional growth of the body mass index (BMI = weight/kg divided by the height in m²).

When the BMI is below 25 kg/m² (the norm) the incidence of hypertension is about 15%. When the BMI is over 25 kg/m², the incidence of hypertension is 38% – in men and 42% – in women. When the BMI is over 30 kg/m² the risk of stroke increases by 32%. There is a close connection between abdominal obesity and arterial hypertension. The centimeters of the waist circumference, which carry an increased cardiovascular risk, are over 102 cm for men, and 88 cm – for women.

Weight reduction through a low calorie diet and increased physical activity can affect obesity and this is what is recommended as the first and most significant step in the body weight reduction therapeutic approach, and hence as the first measure to reduce cardiovascular risk, to prevent and/or treat diabetes mellitus type 2. Body weight reduction leads to blood pressure reduction. Weight reduction by 10 kg results in a decrease in systolic blood pressure by 5 to 20 mm/Hg, and also improves the medication response.

Since coming into office, the government has appointed 70 doctors and 77 nurses in emergency assistance, said the Health Minister Dr. Peter Moscow in Veliko Tarnovo, noting that emergency assistance is a priority in the healthcare reform.

According to him, the reason for appointing new employees was that the government very quickly had been able to create financial and economic prerequisites for specialists to want to work in the emergency centers again. “For the same period, the country provided 56 ambulances and 14 centers were equipped with devices for telemedicine. This is expensive and advanced equipment, which allows quick telecommunication. Together with Prime Minister Borisov and Minister Pavlova, we will be able to ensure additional €85 million for emergency assistance. With this sum, we will renew the entire vehicle fleet and equip all emergency departments,” said the Minister.

The aim is that 7 million Bulgarians across the country have access to emergency assistance within 30 minutes by the end the mandate, he explained and clarified that two helicopters will be provided for the purpose.
The Health Minister also informed that through transatlantic cooperation with Romania we are expecting even more EU funding.