Bulgaria has undertaken severalsignificant health sector reforms during the past decade,but a large unfinished policy agenda remains.Compared toother EU countries, the share of out-of-pocket spending issignificantly higher in Bulgaria, while government spendingon health is relatively low.Various indicators of reportedpublic satisfaction with the health system in Bulgaria arefrequently the lowest in the EU. The hospital sector hasseen rapid growth in recent years, putting thesustainability of the system in doubt and crowding outexpenditures on more pressing priorities such as primaryhealth care and the reimbursement of cost-effective drugs.Contrary to the imperative of improving health systemefficiency, in recent years the Bulgarian hospital sectorhas grown in number of facilities, total number ofhospitalizations, and the budget share dedicated toinpatient services.Each of these indicators is out of linewith European standards. The primary health care system iswell established but does not live up to its potential toprovide efficient, high-quality care.Spending on primaryhealth care is low, referral rates to higher levels of careare excessive, and the payment method does not provideadequate incentives for improved service provision. Newby-laws on pharmaceutical policy and a new positive druglist mark a step forward, but important risks remain.Thenew drug list includes many new and expensive drugs, but theprevious practice of using waiting lists to ration drugaccess in response to fixed budgets is no longer beingimplemented.As a result the new drug list poses a threatto the NHIF drug budget in 2009 which was originallyprogrammed to be flat. The future direction of the nationalhealth insurance system needs to be clarified with referenceto the key lessons emerging from the broad internationalexperience with insurance system reform.In the short-term,protect health spending to mitigate the impact on the poor;and stabilize the drug budget during the final months of2009, for example by considering a re-introduction ofwaiting lists for certain high-cost drugs and ensuring thatadequate funds are available for nationally procured drugs.In the medium-term, initiate hospital sector restructuringin line with the master plan; and consider changing thefinancial incentives for hospitals, for example by enablingthe NHIF to selectively contract with hospitals and todetermine their budgets on the basis of case mix andprojected service volume using the more accuratediagnosis-related groups (DRGs) instead of the currentClinical Care Pathways(CCPs); Focus on measures to improvethe quality of services provided by strengthening theinstruments of licensing and accreditation, for examplethrough the establishment of an independent entityresponsible for these functions; creating a link betweenhospital payment and information about the quality of theirservices; and reviewing the Clinical Care Pathways in lightof up to date, international evidence on cost effectivetreatment protocols.
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