Dimova Antoniya, Rohova Maria, Moutafova Emanuela, Atanasova Elka, Koeva Stefka, Panteli Dimitra, van Ginneken Ewout
Department of Health, Economics and Management, Varna University of Medicine, Bulgaria.
Health Syst Transit. 2012;14(3):1-186.
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.
在过去20年里，保加利亚的人口发展呈现出人口减少、粗出生率低、生育率低、死亡率高以及人口老龄化的特点。自21世纪初以来政治局势的稳定以及自2000年代中期以来的经济热潮是出生率和生育率略有上升以及标准化死亡率略有下降的重要因素。总体而言，保加利亚在大多数死亡率和发病率指标方面落后于欧盟平均水平。2008年出生时的预期寿命达到73.3岁，主要死因是循环系统疾病、恶性肿瘤和呼吸系统疾病。总体而言，最重要的风险因素之一是吸烟，2008年与吸烟相关原因的平均标准化死亡率是欧盟15国平均水平的两倍。保加利亚的卫生系统具有有限国家干预主义的特点。卫生部负责国家卫生政策以及卫生系统的整体组织和运作，并与所有与公共卫生相关的部委进行协调。保险系统中的关键角色是被保险人、医疗服务提供者和第三方支付者，第三方支付者包括国家健康保险基金（社会健康保险（SHI）系统中的单一支付者）和自愿健康保险公司（VHIC）。卫生筹资由公共和私人混合组成。医疗保健资金来自强制性健康保险缴款、税收、自付费用（OOP）、自愿健康保险（VHI）保费、企业付款、捐赠和外部资金。卫生总支出（THE）占国内生产总值（GDP）的比例从1995年的5.3%增至2008年的7.3%。在2008年，这一比例中自付费用占36.5%、社会健康保险占34.8%、卫生部支出占13.6%、市政支出占9.4%以及自愿健康保险占0.3%。卫生部门的非正式支付占自付费用总额的很大一部分（2006年为47.1%）。卫生系统在经济上不稳定，医疗保健机构，尤其是医院，资金不足。门诊医疗保健规划基于地域原则。对国家和市政卫生机构的投资由机构资本中的国家或市政份额提供资金。2009年第一季度，卫生工作者占劳动力总数的4.9%。与其他国家相比，医生和牙医的相对数量特别高，但护士的相对数量仍远低于欧盟15国、欧盟12国和欧盟27国的平均水平。保加利亚面临着专业人员流动性增加的问题，这正变得尤其具有挑战性。急性护理床位供应过剩，长期护理和康复服务供应不足。1989年后的医疗保健改革主要集中在门诊护理，医院部门的重组仍在政府议程上。公民以及医疗专业人员对医疗保健系统不满意，公平是一项挑战，不仅因为健康需求存在差异，还因为社会经济差距和地域不平衡。进一步改革的必要性十分明显，特别是考虑到人口的健康状况不佳。系统的结构改革和竞争力提升以及对改革理念和措施的全面支持是取得成功进展的先决条件。
