1. Svetlana Spassova, MD Ministry of Health, Bulgaria Chisinau 07.11.2008

3. WHO's health system performance framework

5. The Health System in Bulgaria Revenue collectionHNIF: obligatory population-wide health insurance (6%); MoH: budget transfers (4,5% of GDP) Private health insurance companies: voluntary (personal) health insurance (<10% of HC services market); OPP PoolingNHIF; MoH; private health insurance companies PurchasingNHIF – for health insured persons, based on solidarity; MoH – for uninsured (emergency, birth assistance, hospital psychiatric service, blood and blood products, transplantations, certain therapies and pharmaceuticals ) Private health insurers: additional services (extended package) ProvisionMedical establishments: both private and on contract with purchasers

6. Addressing inequalities in Bulgaria Addressing the particular health needs of: - Uninsured people; - People with low income; - Disabled people; - Vulnerable groups: children, youth, elderly; - Minorities; - People, suffering from specific diseases.

7. Addressing inequalities: Stewardship Legislative provisions: The Law on Health and secondary by-law guarantee access to certain healthcare services, regardless of insurance status; The National Health Strategy: putting the issue of addressing inequalities on the political agenda; National strategies and programs targeting disadvantaged groups: focus on information, disease prevention, provision of services and treatment; The EU-Pre-accession instruments (the PHARE- program) and the Structural funds

8. Addressing inequalities: Investment and training Availability of qualified human resources- specialization system financed by the state; Investments in infrastructure and facilities – state financed investment policy provided by MoH, projects financed under the pre-accession and Structural funds; municipal budgets Access to pharmaceuticals – legislation on pharmaceuticals and medical devices; control of prices of prescription drugs linked to external and internal reference and inflation; positive drug list

9. Addressing inequalities: Service delivery State budget financed access to emergency healthcare, midwifery care, organ transplantations and follow up treatment, central procurement of pharmaceuticals for cancer diseases, rare disease, blood disorders, transplants and dialysis; immunization and vaccines, neonatal screening of genetic diseases; access to national, regional and community programs, transportation, mobile structures and outreach programs. National programs, targeting: - disadvantaged groups: minorities, people with mental disorders, people with rare diseases, etc. - diseases, representing significant socio-economic burden: cancer, tuberculosis, HIV/ AIDS, etc.

10. Addressing inequalities: Financing National budget spending on: - health services for uninsured; - health services for specific vulnerable groups; - national, regional and communal programs. - infrastructure External funding: - EU fund spending on specific projects, targeting minorities or diseases, affecting predominantly vulnerable groups. - The Global Fund to fight AIDS, tuberculosis and malaria - infrastructure, regional development, strengthening of human resources and administrative capacity;

11. Strengthening health system - performance and challenges Improving health in equitable way requires: Functions of the health system, related to reforms Reform plans, oriented towards goals Overall goals, split into specific objectives Measurable intermediate objectives, leading to achievement of national objectives

12. Addressing inequalities: Challenges Defining and implementing reforms and investments, aimed at those most in need of care; Balancing competing demands and setting clear policy priorities Creating awareness in order to prevent conflicts between different members of society Developing programs, that deliver added value and have defined measurable outcomes Ensuring the availability of qualified health force; creating incentives for medical professionals Developing PPP

13. Addressing inequalities: Challenges Financial restrictions require prioritizing Reducing financial barriers which hinder access to needed care Ensuring continuity: a stable flow of resources Reaching the disadvantaged people; monitoring the responsiveness of services Evaluating the impact of service delivery strategies.

14. Measuring Outcomes: Conclusions Measures aimed at addressing inequalities strengthen health system performance, if resulting in Better health throughout the entire population; Responsiveness of the system to specific needs and vulnerabilities; Sufficient funding and optimal redistribution so as to enable universal access to health services.

15. Bulgaria

16. Thank you for your attention! Svetlana Spassova, MD National Health Policy Director, Ministry of Health - Bulgaria sspassova@mh.government.bg