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. World Health Organization 2018 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).