Need of the Service Medical Home Care and Perspectives for Public-Private Partnership in Bulgaria1

YANAKIEVA, Antoniyaa, VODENITCHAROVA, Alexandrinab, and ALEKSANDROVA, Magdalenac

a Department of Health Policy and Management, Faculty of Public Health, Medical University, Sofia, Bulgaria, e-mail:
b Student Master, Faculty of Public Health, Medical University, Sofia, Bulgaria, e-mail:
c Vice-Dean, Faculty of Public Health, Medical University, Sofia, Bulgaria, e-mail:

Abstract The modern Bulgarian Health Care System is facing the challenges of both the worsened national economic environment and the need for new strategies for dealing with the full scope of resources spent and results achieved. Due to the fast process of population ageing, a low crude birth rate, chronic disease and disability as well as the emigration of young people from the country, Bulgaria is fighting the headlong rise of expenses for treatment and maintaining of the health state of its people. The lack and deficiency of suitable health care institutions for post-medical treatment and constant care, as well as the inefficient spending of financial resources from the healthcare installments are only part of the problems in the Health Care System. The decrease of medical care personnel (shortage of medical nurses, physicians, rehabilitation specialists etc.), particularly in small towns and remote populated areas restricts the access to medical help and quality healthcare services to patients in those areas. The provision of adequate care for the needing patients represents a great challenge to our Social System. The consecutive development of the Social and the Health Insurance Systems is of vital importance, as in the future, the problems connected to the need for home medical care will be on the rise.

Keywords medical home care, public-private partnership, Bulgaria

1  The Service Medical Home Care

The service Medical Home Care represents basic medical care, taking care of patients, respectively children, adults and elderly people, and psychiatric care. It is delivered either at the patient’s home or on the premises of the hospital. The activity is being prescribed and monitored by the respective physician-specialist. Intense relationships with patients taking responsibility for making critical decisions a patient’s life, the anticipation of possible negative developments and the concomitant mental tension leads to stress, that is why medical professionals should have a special psychological knowledge and experience. In terms of financial crisis in health outpatient care is effective modern alternative for high quality, efficiently and affordably overcome the problem of overhospitalizations in the country. Depending on the disease and the patient, there are different formats of the proposed ambulatory care. The possibilities are as follows: hourly watch and 24/ 7.

Medical patronage mainly provides professional care to patients with the following health problems:

  • Orthopaedic and Trauma: fractures and injuries in different locations with available care at home or in hospital;
  • Surgery: care for patients in the postoperative period;
  • Neurology: care for patients with acute cerebral circulation disorders, dementia, paralysis. These can include rehabilitation, massage, help to restore speech after stroke ejected;
  • Therapy: patient care after myocardial infarction, pneumonia and other diseases of common therapeutic character. Prevention of pneumonia and post surgical bedsores.
  • Oncology: care for patients with different stages of cancer.
  • Care for elderly people.

2  The Bulgarian Health Care System

The health insurance care system in Bulgaria is compulsory. Contributions to it are determined as a percentage of the income and are paid jointly by the insured (workers, employers and government). The insurer of the system is represented by the National Health Insurance Fund (NHIF). The Health Insurance Legislation introduces a package of the medical services, guaranteed by the NHIF budget. This package mentioned above is determined by the Minister of Health. The process is organized as following:

  • Every year the NHIF and the professional organizations of the doctors and dentists receive and sign the National Framework Agreement. Subject of the contract are the prices and services, included in the package. The patients are obliged to pay the NHIF and cannot choose which services to receive, at what price and where. From that point of view it could be said that the end consumers of that care system are ignored.

Because NHIF is a monopolist, very often it happened that the package of guaranteed medical services does not correspond to the actual needs of the health services and the practice. In Bulgaria, according to the statistics, life expectancy at birth reached 74.08 years in 2013 (male 70, 49 years, female 77, 89 years)2. The main three causes of death being diseases of the circulatory system, malignant neoplasms and diseases of the respiratory system. 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 that take actively part are the insured individuals, the health care providers and the third party payers, In that number the NHIF is comprised, as well as the single payer in the social health insurance (SHI) system, and voluntary health insurance companies (VHICs). Health financing consists of a public-private mix. Health care is financed from compulsory health insurance contributions, taxes, out-of-pocket (OOP) payments, voluntary health insurance (VHI) premiums, corporate payments, donations and external funding. For example, the total health expenditure (THE) as a share of gross domestic product (GDP) increased from 5.3% in 1995, 7.3% in 2008, 7,2% in 2009, 7,6% in 2010, 7,3% in 20113. Later on it is 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). Territorial principle is observed in planning of outpatient health care. Bulgaria is faced with increased professional mobility, which is becoming particularly challenging. It could be easily seen that there is an oversupply of acute care beds and an undersupply of long-term care and rehabilitation services. Also the health care reforms after 1989 are mainly focused on ambulatory care. As a result 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 low health status of the population shows undoubtedly the strong need for further reform. The right prerequisites for successful progress are actually structural reforms, increased competitiveness in the system as well as an overall support of reform concepts and measures4.

3  Need of the Service Medical Home Care

In the present elaboration the possibilities for public-private partnership in the area of medical services at the patient’s home are being examined based on a study of the population’s needs and the medical specialists’ opinion, as well as on the current legislative system. The inquiries have been held among 300 bedridden patients in hospitals, who are directly related to the activity Medical Home Care, as they represent the main target group for this service. The second study has been held among 400 specialists working in the country’s medical institutions. The inquiry data has been organized into a special table and the information has been processed by the statistical and analytical program SPSS (Statistical Package for Social Sciences). A number of analyses have been prepared of one-dimensional distributions of all the questions, of two dimensional distributions, of connections between quality factor and result, between quality factor and quantity result, between quantity factor and quality result, as well as an interpretation of the numerical characteristics and graphical illustration of the data. The adequate care taking and their provisioning for the people in need represents a big challenge for our social system. The consequent development of the social and health insurance system is of main necessity, since in the future the place of the problems with regard to the need of taking care in home conditions shall become even more important. A comparison of the age structure of the people of the Republic of Bulgaria in the last decades shows that together with the relative diminishing of the number of young people it is impressive the significant growth of the number of the older people, especially in the age group of over 70 years /Fig. 1/.

Figure 1: Population distribution of the Republic of Bulgaria by age and sex for 2011

From the research covering 400 medical experts with regard to the services, which are included in the activity Medical Home Care one has obtained the following results presented in Table 1. They consider this service as related mainly with home visits and observation by the nurse (74,7 %), visit by a social worker (60,9 %), observation by a doctor (52,9 %), change of bandage, placing injections etc. (49,1 %), visit by a care taker (44,9 %), visit by a rehabilitator (42,4 %), performance of sanitary services (33,6 %), visit by a psychologist (32,6 %), performance of rehabilitation and medical sport activity (30,6 %), observation by a midwife (27,3 %), performance of activities for social adaptation and reintegration (23,8 %), provisionin of nurse position (20,3 %), performance of consultative investigation by an expert (19,8 %), performance of washings (19 %), performance of activities on the mental adaptation of the patients (17,8 %) etc: all enumerated activities, supply of food (2 %).

Table 1: Services provided by Medical Home Care according to medical experts
Surveillance by a nurse74.70299
Visit from social worker60.90244
Observation from doctor52.9212
Changing bandages, injections and others49.1196
Visit a caregiver44.9180
Visit from rehabilitator42.4170
Sanitary services33.6134
Visit from a psychologist32.6130
Rehabilitation and medical gymnastics30.6122
Observation from midwife27.3109
Action on social adaptation and reintegration23.895
Nursing post20.381
Consultative examination by a specialist19.879
Performance of lavage1976
Activity of psychological adaptation17.871

To compare on the Fig. 2 are given the results from the patient´s survey about their preferred services.

Figure 2: Preferred services offered by Medical Home Care by patients

4  Organizations, which offer Medical Home Care in Bulgaria

National Program "Assistants to disabled people"
The only operative national program covering the social aspect of the Medical Home Care is the National Program "Assistants to disabled people" set up in 2003 with the activity "Personal Assistant". The program provides quality care at home to gravely ill persons and to the disabled as well as it achieves a social adaptability in the framework of the current disability.The users of the activity"Social Assistant" use social services intrinsic to the activity within a particular time limit. The inclusion into the program of patients is open only to persons not using social services such as Personal Assistant or Social Assistant delivered by other organizations, companies or donor’s programs.

The program is in conformity with the principles of the Equal opportunities for the disabled National Strategy, the principles of deinstitutionalization, the European practices and the principles of employment in the EU. The activity Peronal Assistant is financed by the State Budget.The activity Social Assistant is accomplished on the principles of co-financing on three levels: State Budget, Municipal Budget and patient’s fees.

The Insurance Decent Old Age
The implementation of the insurance Decent Old Age was amongst the initial proposals of the pension reform of 2010. It was suggested it would represent 1% of each one’s salary.The idea was that the receipts from it would cover the allowance for sick and single elderly persons as the additional income would be collected in a separate fund within the National Social Insurance Fund. Due to the increase of the insurance burden on people the idea was rejected. In 2011 its implementation was included in the Action plan for gender equality.

The NGOs play a key role in the realization of the democratic participation principles. A major characteristic of those organizations is their independence from the State and other social sectors. Beside the independence, the NGOs hold a varied and precious experience in areas providing reliable and stable development of society.

The Bulgarian Red Cross
The Bulgarian Red Cross implements the programe "Home care" as an integrated model for provision of health care and social services at home to elderly, chronically ill patients and disabled persons.This model is based on the experience of the Swiss association "Spitex" and has successfully been adapted to Bulgarian conditions. The center for home care analyses and evaluates the needs of patients ,organizes staff training, provides the services and monitors their quality.
International NGO "Caritas"
In 1993 by a decision of the Episcopal Conference of the Catholic Church "Caritas Bulgaria" has been established. Caritas Bulgaria is a non-profit organization for social benefit and it realises its social activity in support of the vulnerable social groups through its structures and collaborators in various populated areas of the country.

At present six centers for home care in the towns of Rousse,Belene,Rakovski, Malko Tarnovo, Sofia and in the village of Jitnitza are functioning. However, these programs cover only a minimal part of the needs of the underpriviledged,of chronic disease patients, of patients in need of rehabilitation and home care and single elderly persons. Set against the background of ineffective spending of health funds and the marked increase of sickness rates in the country this service provides a possibility to limit and even decrease the rising costs of healthcare, especially the hospital stay expenses. From a social point of view, the countries where this service has been delivered for several years /for exemple Germany, Austria, Switzerland/ observe a rise in the quality of life and improvement of psychic health of patients.The needs of the individual person are set as a priority number one when defining the kinds and the volume of the services to be provided to him/her.

5  Financing of the Service Medical Home are in Bulgaria

According the researches made amongst the medical professionals as well as bed-ridden patients in, the majority of the population would not take advantage of such a service unless it is being financed by an institution or family and close relatives due to the impossibility to allocate enough money from the personal budget. This is the reason why the provision of Medical Home Care should be a priority in developping the relevant legislation. It could be a mixture of different financial mechanisms and various service providing organizations. The financing could be shared between the State, the National Health Insurance Fund, the Voluntary Health Insurance Funds, the NGOs and payment or extra-payment by patients.

Figure 3: Organizations, which should deliver Medical Home Care, according the medical professinals

Despite the existing legislation, regulations, organizations and programs for matching the needs of the population for health services such as the Medical patronage at home, both medical and social, the capacity of the operativ institutions at the moment is absulutely inadequate to include a large group of people in need. The activities are underfinanced and insufficient. The financing of particular programs is not a stable and long term decision to the problem of those people’s needs. Much more attention shoud be paid to the implementation of a"specialized unit" for home care and more specifically for Medical Home Care. The insufficiency of the services at the moment finds expression in the inadequate coverage by the operative organizations and programs. There are areas in the country where patients do not have access to such a service.

The beneficial use of good world practices with proven efficiency for such kind of service, as well as the organizational skills of leading academics and medical professionals is bound to raise the quality of patients’ lives, to increase the incomes of medical professionals and to decrease the cost of hospital stay.

6  Conclusions

Patients have been integrated in the active professional, cultural and social life, which are restoring for longer periods. One improves the social environment and life style.

The servicing on the activity Medical Home Care requires by itself placing the patient in the centre of attention and cares according to his/her sole needs and expectations.

Against the background of the current economic context in Bulgaria, the service Medical Home Care will play an important role in the healthcare system in the future.

The service Medical Home Care allows limiting and even reducing rising health care costs. This includes the rapidly increasing costs of hospital stay and the more efficient use of financial resources.

Majority of the population is not likely to benefit from this type of service if it is not funded by an institution or relatives due to the inability to allocate sufficient funds from the household budget. With the increasing age of the patient, his/her inability to pay for such service also increases.

For the population in the active workforce, it is critical to provide decent care for their sick relatives, which in turn would reduce their absence from work.

According to respondents, most demanding duties include first, the personal hygiene of the patient, and second – the special medical care required.

Service under the Medical Home Care requires to put the patient at the center of attention and care, fully consistent with its expectations and desires.

The implementation and the provision of funding for the Medical Home Care will provide better medical care for bedridden patients, severely ill and elderly at home.

The implementation and the provision of funding for the Medical Home Care will reduce the cost of hospital treatment of people who can be cared for in their own home.

The implementation and the provision of funding for the Medical Home Care in cooperation with NGOs will bring the Bulgarian health care system closer to the healthcare systems of developed countries, which have shown the effectiveness of this type of service.


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International NGO "Caritas"

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RESEARCH ON THE POPULATION NEED OF THE SERVICE “MEDICAL HOME CARE” IN BULGARIA, Grant 17 / 2010, Council of Medical Science, Medical University Sofia, Bulgaria


The World Bank

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Vizev M., Kr. Vizeva, А. Vodenitcharova, V. Petkov (2013): Medical and social aspects of health care for adult patients with type 2 diabetes, Journal Health and Science, 2: 12-15

World Health Organization 2012, on behalf of the European Observatory on health systems and Policies (20 December 2013)‎ (20 January 2014)‎ (22 January 2014)


Yanakieva, A. Y.; Vodenitcharova, Y. Y.; Bancheva, M. A. (2014): Need of the Service Medical Home Care and Perspectives for Public-Private Partnership in Bulgaria. In: Planet@Risk, 2(4), Special Issue on One Health: 298-302, Davos: Global Risk Forum GRF Davos.

This article is based on a presentation given during the 2nd GRF Davos One Health Summit 2013, held 17-20 November 2013 in Davos, Switzerland (
The World Bank
World Health Organization 2012, on behalf of the European Observatory on health systems and Policies