BULGARIA | Emergency | Healthcare system
Healthcare in Bulgaria
Bulgaria has both a compulsory (basic) and a voluntary health insurance scheme. All Bulgarian citizens as well as people with dual citizenship and foreigners who are permanent residents in the country benefit from compulsory health insurance (usually referred to in Bulgaria as “health care coverage/security”). It is administered via the National Healthcare Fund and guarantees anyone who is insured free access to basic medical care. Each month, employers are required to pay the equivalent of 8% of their employees’ gross salary into the National Healthcare Fund; part of this sum is a contribution from the employe, and part is withheld from the employee’s income. All children, students, including full time college students under the age of 26 (also applies to international students), retirees and military personnel are paid for by the state. Unemployed individuals are responsible for making their own monthly payments to the fund. If no payment is made for three consecutive months, an individual is considered uninsured and required to pay for any medical treatment in full. There are a number of exceptions, e.g. those who are unemployed or socially disadvantaged (including refugees) may be treated via the National Healthcare Fund or through social programmes if they are eligible.
In addition to the compulsory health insurance, individuals can choose a voluntary health insurance plan to supplement their basic insurance in order to increase the amount of money available for their medical care. These plans/policies are offered by private insurance companies and can be short or long term – the specific length is chosen by the beneficiary at the time of taking out the contract. The main focus of such policies is accidents, emergencies, hospitalization, medical expenses during travel, critical illnesses, etc., but they can also cover regular complex health care including prevention of illnesses (e.g. regular check-ups).
Everyone covered by the compulsory health insurance system is required to choose a general practitioner (GP) who is the first person they will go to in case of a health problem. There is a very small charge (the equivalent of 1 – 2€) for each visit to the GP (notwithstanding the insurance). GPs’ offices are located in former polyclinics – now known as Diagnostic Consultative Centres (DCC). It is the GP who decides whether or not to refer the patient to a specialist for further check-ups, scans or hospitalization. The GP provides the patient with a certificate guaranteeing him/her the right to access the next level of free treatment in the healthcare system for a particular complaint. It is important to note that GPs are restricted in the number of referral certificates they can give out per month, so there is no guarantee that every patient will be given one, particularly towards the end of the month. Decisions are made by the GP on the basis of the severity of the patient’s medical condition. The health system has clearly defined “clinical pathways” for each type of illness and these specify the number of days that a patient is likely to have to remain in hospital for a particular complaint.
The system described above applies to Bulgarian citizens as well as to citizens of other EU countries, the European Economic Area (EEA) and Switzerland. Anyone who is not a citizen/permanent resident of Bulgaria, must have an insurance card, e.g. the European Health Insurance Card (EHIC), confirming that they have appropriate health insurance. They will also be asked to fill out a form and provide their ID. Anyone from an EU country, the EEA or Switzerland, who is not able to provide evidence of appropriate health insurance, is required to pay for medical examinations and treatment. Foreign citizens (regardless of their nationality) working legally in Bulgaria are subject to the same health insurance laws as Bulgarian citizens. Patients from non-EU countries are strongly advised to have appropriate private health insurance before visiting Bulgaria as they will be required to pay for their medical treatment.
Bulgaria has both public and private hospitals, DCCs and emergency centres. All public and most private centres work with the National Healthcare Fund: When a patient is treated/hospitalized, each of these centres (public or private) can claim the corresponding amount of money from the National Healthcare Fund (provided they have a contract with it), i.e. the state’s set rate, including agreed “clinical pathways” for hospitalization. However, it is possible that the cost of procedures in some private hospitals might be higher than this pre-determined rate. In such cases, the patient has to pay the additional amount out of his/her own pocket or make use of private insurance funds (if he/she has such a policy). If the patient prefers, he/she can go straight to a private centre and pay the cost of the medical procedure directly. Private centres offer better facilities, enhanced patient care and in many cases state-of-the-art technology. However, the best specialists and equipment for medical procedures are located at university clinics which are always part of the public sector.
Emergency medical care
By law, emergency medical care (stabilizing the patient’s condition) is provided in Bulgaria to anybody who needs it, regardless of their religion, nationality/ethnicity and whether the patient has or does not have medical insurance. However, all further treatment must be paid for either through an insurance policy or directly.
Every city and town has an emergency medical unit. Smaller rural settlements are serviced by the emergency medical centre in the nearest city/town. If a patient needs hospitalization, he/she is taken to the nearest duty hospital – such hospitals are only found in larger cities/towns. The telephone number for emergency calls in Bulgaria is 112. Calls to this number are free of charge and can be made even when all other outgoing calls are limited or not allowed. As soon as the emergency operator receives the call, it is passed to the appropriate emergency service – emergency health centre, police, fire brigade, etc. Larger cities also have private emergency medical centres, each with their own emergency phone number. Since every GP has a contract with one such private centre, the emergency call there and the service is also free for anyone with health insurance. Private medical centres generally have newer ambulances and respond to emergency calls more quickly.
In emergency situations, where the patient is unable to see the GP in the first instance (e.g. the GP is not on duty), he/she can go straight to the Diagnostic Consultative Centre (DCC) where his/her GP works and be examined by the particular duty doctor who has a contract with the patient’s GP. The majority of staff working at emergency call centres e.g. nurses, laboratory assistants and physician assistants (Feldsher) are graduates but are not always in a position to make skilled judgements about the severity of a particular emergency.
In the case of mountain emergencies, the Mountain Emergency Service operates as part of the Bulgarian Red Cross and has its own first aid centre and separate emergency phone numbers which are listed on its website. Most units provide a 24-hour service.
Significant constraints on the avalibality of emergency medical care
The recent introduction of the unified emergency telephone number (112) means that the level of coordination across the different emergency services is still not always as efficient as it should be. There can be delays in emergency calls reaching the appropriate emergency service and in the time it takes for an ambulance to arrive at the scene of an emergency. Delays can also occur as a result of too few staff being on call at the public emergency centres and a lack of ambulances. Not all emergency centres have up-to-date technology and equipment, including ambulances. In addition, the emergency service is not able to guarantee that there are English (or other languages) speaking individuals present, and it is advisable for patients to be able to speak some Bulgarian or to have someone with them for language support.
Doctors working at the emergency centres are usually GPs. Outdated equipment and poor working conditions make this area of medical service unpopular. A solution to this is the introduction of the paramedic as a recognised profession in Bulgaria. Now that the role has been included in the register of professions, the training of Bulgaria’s first paramedics can begin. A major and longstanding issue which has yet to be resolved is what happens when an emergency patient needs to be hospitalized, but is unable to walk to the ambulance. Since this is not the responsibility of any member of the emergency team, it is currently customary for family members or neighbours to assist. Hopefully, including paramedics in each team will resolve this issue in the future.
Doctors' surgeries
You may visit the doctor of your choice in Bulgaria, but once you choose your GP, you should stay with him/her unless you are unhappy and want to change your GP – then you have to do the paper work again. If you need to see a doctor, you should have a friend or colleague recommend one. Visits to the doctor are usually made by appointment.
Costs
The cost of medical treatment in Bulgaria is generally lower than in other European countries.
Prescriptions
These are the most popular drugs that are available in pharmacies without prescription:
- Basic analgesia, e.g. Analgin, Benalgin, Aspirin, Paracetamol, Coldrex
- Medicine with local antiinflammation effect, e.g. Efisol
- Decongestants, e.g. Xylomethazolin, Vybrocil
- Spasmolitics, e.g. Buscolisin, Spasmalgon, No-spa
- Creams with antiallergic effect, e.g. Flucinar, Elocom, Lorinden
- Antitussives, e.g. Sinecode, Prospan, ACC, Mucosolvan
- Vitamins
- Bandages, dressings, plasters, bandaids
In Bulgaria, you usually can’t buy any medication at the supermarkets.