A comparison of health system responses to COVID-19 in Bulgaria, Croatia and Romania in 2020.

This article compares the health system responses to COVID-19 in Bulgaria, Croatia and Romania from February 2020 until the end of 2020. It explores similarities and differences between the three countries, building primarily on the methodology and content compiled in the COVID-19 Health System Response Monitor (HSRM). We find that all three countries entered the COVID-19 crisis with common problems, including workforce shortages and underdeveloped and underutilized preventive and primary care. The countries reacted swiftly to the first wave of the COVID-19 pandemic, declaring a state of emergency in March 2020 and setting up new governance mechanisms. The initial response benefited from a centralized approach and high levels of public trust but proved to be only a short-term solution. Over time, governance became dominated by political and economic considerations, communication to the public became contradictory, and levels of public trust declined dramatically. The three countries created additional bed capacity for the treatment of COVID-19 patients in the first wave, but a greater challenge was to ensure a sufficient supply of qualified health workers. New digital and remote tools for the provision of non-COVID-19 health services were introduced or used more widely, with an increase in telephone or online consultations and a simplification of administrative procedures. However, the provision and uptake of non-COVID-19 health services was still affected negatively by the pandemic. Overall, the COVID-19 pandemic has exposed pre-existing health system and governance challenges in the three countries, leading to a large number of preventable deaths.

Bulgaria: Health System Review.

This analysis of the Bulgarian health system reviews developments in its organization and governance, health financing, health care provision, health reforms and health system performance. With the 2015 National Health Strategy 2020 at its core, there have been ambitious reform plans to introduce more decentralization, strategic purchasing and integrated care into the Bulgarian social health insurance system. However, the main characteristics of the Bulgarian health system, including a high level of centralization and a single payer to administer social health insurance, remain intact and very few reforms have been implemented (for example, the introduction of health technology assessment). There are multiple reasons for this, of which political fragility and stakeholder resistance are among the most important. Overall, Bulgaria marked notable progress on some health indicators (for example, life expectancy and infant mortality) but generally progress lags behind EU averages. What is more, the system has not been effective in reducing amenable mortality, as reflected in the unsteady improvement patterns in mortality due to malignant neoplasms. This is despite an increase in total health expenditure as a percentage of gross domestic product to 8.2% in 2015. The overall high out-of-pocket spending (47.7% of total health spending in 2015) has been growing and is increasingly worrisome. It evidences the low degree of financial protection by the Bulgarian social health insurance system and exacerbates the already considerable inequities along socioeconomic and regional fault lines. For instance, there are regional imbalances of medical professionals, which are more concentrated in urban areas, and accessibility to physicians is further deteriorating, especially in rural areas. Current reforms have to tackle these challenges and build consensus among stakeholders of the health system to unlock the standstill.

An innovative approach to participatory health policy development in Bulgaria: The conception and first achievements of the Partnership for Health.

The Bulgarian Partnership for Health was established in 2015 as a new forum for health policy formulation and discussion. The Partnership presents a new approach of structured and sustained stakeholder involvement to overcome the lack of public participation in health policy development and implementation. Constituted as a permanent consultative body to the Council of Ministers, the Partnership engages a wide variety of stakeholders and professionals to shape and improve health policies. The shared governance of the Partnership between the Minister of Health and a patient organisation supports the elaboration of legislative acts based on the stakeholders' collaboration in priority areas. The governance and organisational structure of the Partnership assures capacity building, fast mobilisation of experts, continuity of stakeholder involvement, and increased responsibility in health policy development and implementation. This type of participatory approach may help reconcile initially opposing positions and foster reforms often impeded by political antagonism. Persisting challenges are a rather slow process of policy development and different perceptions of key concepts among the stakeholders. As policy-making in many countries in Eastern Europe suffers from political distrust, the Partnership's approach of involving experts - and not only politicians - could provide inspiration also to other countries, which have struggled with inconsistency of health policies pursued by different governments.

Drug Policy in Bulgaria.

Bulgaria has a mixed public-private health care financing system. Health care is financed mainly from compulsory health insurance contributions and out-of-pocket payments. Out-of-pocket payments constitute a large share of the total health care expenditure (44.14% in 2014). The share of drugs expenditure for outpatient treatment was 42.3% of the total health care expenditure in 2014, covered mainly by private payments (78.6% of the total pharmaceutical expenditure). The drug policy is run by the Ministry of Health (MoH), the National Council on Prices and Reimbursement of Medicinal Products, and the Health Technology Assessment Commission. The MoH defines diseases for which the National Health Insurance Fund (NHIF) pays for medicines. The National Council on Prices and Reimbursement of Medicinal Products maintains a positive drug list (PDL) and sets drug prices. Health technology assessment was introduced in 2015 for medicinal products belonging to a new international nonproprietary name group. The PDL defines prescription medicines that are paid for by the NHIF, the MoH, and the health care establishments; exact patient co-payments and reimbursement levels; as well as the ceiling prices for drugs not covered by the NHIF, including over-the-counter medicines. The reimbursement level can be 100%, 75%, or up to 50%. The PDL is revised monthly in all cases except for price increase. Physicians are not assigned with pharmaceutical budgets, there is a brand prescribing practice, and the substitution of prescribed medicines by pharmacists is prohibited. Policies toward cost containment and effectiveness increase include introduction of a reference pricing system, obligation to the NHIF to conduct mandatory centralized bargaining of discounts for medicinal products included in the PDL, public tendering for medicines for hospital treatment, reduction of markup margins of wholesalers and retailers, patient co-payment, and the introduction of health technology assessment. Although most of the policies have been introduced since 2011, there is still weak evidence for improvement regarding cost containment and effectiveness.

Bulgaria health system review.

In the last 20 years, demographic development in Bulgaria has been characterized by population decline, a low crude birth rate, a low fertility rate, a high mortality rate and an ageing population. A stabilizing political situation since the early 2000s and an economic upsurge since the mid-2000s were important factors in the slight increase of the birth and fertility rates and the slight decrease in standardized death rates. In general, Bulgaria lags behind European Union (EU) averages in most mortality and morbidity indicators. Life expectancy at birth reached 73.3 years in 2008 with the main three causes of death being diseases of the circulatory system, malignant neoplasms and diseases of the respiratory system. One of the most important risk factors overall is smoking, and the average standardized death rate for smoking-related causes in 2008 was twice as high as the EU15 average. The Bulgarian health system is characterized by limited statism. The Ministry of Health is responsible for national health policy and the overall organization and functioning of the health system and coordinates with all ministries with relevance to public health. The key players in the insurance system are the insured individuals, the health care providers and the third party payers, comprising the National Health Insurance Fund, the single payer in the social health insurance (SHI) system, and voluntary health insurance companies (VHICs). Health financing consists of a publicprivate mix. Health care is financed from compulsory health insurance contributions, taxes, outofpocket (OOP) payments, voluntary health insurance (VHI) premiums, corporate payments, donations, and external funding. Total health expenditure (THE) as a share of gross domestic product (GDP) increased from 5.3% in 1995 to 7.3% in 2008. At the latter date it consisted of 36.5% OOP payments, 34.8% SHI, 13.6% Ministry of Health expenditure, 9.4% municipality expenditure and 0.3% VHI. Informal payments in the health sector represent a substantial part of total OOP payments (47.1% in 2006). The health system is economically unstable and health care establishments, most notably hospitals, are suffering from underfunding. Planning of outpatient health care is based on a territorial principle. Investment for state and municipal health establishments is financed from the state or municipal share in the establishments capital. In the first quarter of 2009, health workers accounted for 4.9% of the total workforce. Compared to other countries, the relative number of physicians and dentists is particularly high but the relative number of nurses remains well below the EU15, EU12 and EU27 averages. Bulgaria is faced with increased professional mobility, which is becoming particularly challenging. There is an oversupply of acute care beds and an undersupply of longterm care and rehabilitation services. Health care reforms after 1989 focused predominantly on ambulatory care and the restructuring of the hospital sector is still pending on the government agenda. Citizens as well as medical professionals are dissatisfied with the health care system and equity is a challenge not only because of differences in health needs, but also because of socioeconomic disparities and territorial imbalances. The need for further reform is pronounced, particularly in view of the low health status of the population. Structural reforms and increased competitiveness in the system as well as an overall support of reform concepts and measures are prerequisites for successful progress.