2. Ensuring sufficient physical infrastructure and workforce capacity
ENSURING SUFFICIENT PHYSICAL INFRASTRUCTURE AND WORKFORCE CAPACITY is crucial for dealing with the COVID-19 outbreak, as there may be both a surge in demand and a decreased availability of health workers. The section considers the physical infrastructure available in a country and where there are shortages, it describes any measures being implemented or planned to address them. It also considers the health workforce, including what countries are doing to maintain or enhance capacity, the responsibilities and skill-mix of the workforce, and any initiatives to train or otherwise support health workers.
2.1 Physical infrastructure
According to Eurostat, the density of hospital beds in Bulgaria (745 per 100,000 inhabitants in 2017) range second in the EU. In 2018 (latest available data), hospital care was provided in 346 health care establishments with 53,173 inpatient beds (NCPHA 2020). The number of ICU beds was 1,876 in 2018 (27 per 100,000 inhabitants) with an average utilisation rate of 54.4%. Bulgaria also has hospital beds dedicated to the treatment of infectious diseases – 776 beds or 11 per 100,000 inhabitants in 2018 (NCPHA 2020). The distribution of hospital beds varies regionally with significant differences between districts.
Before the outbreak of COVID-19 in Bulgaria, the MoH announced some preparatory measures – three big university hospitals in Sofia would transform some clinics to face a possible spread. After the confirmation of first cases, the Ministry reorganised and increased bed capacity for the admission and treatment of coronavirus patients. Suspected cases were initially isolated in hospital settings. However, on March 16, a ministerial order set some criteria for compulsory hospital admission of confirmed cases: elderly (over 60 years) irrespective of symptoms severity, patients with chronic diseases irrespective of symptoms severity, severe forms of the disease, and patients who cannot be isolated at home. Asymptomatic patients or patients in mild condition and without other health issues are required to stay at home and contact their GPs or the respective RHI. Elective surgeries and planned hospital admissions have been postponed. On March 27, the Minister determined by an order the hospitals, hospital wards and the number of beds for treatment of coronavirus patients in every district, divided into two groups depending on the severity and intensive care needs. Private hospitals also provide equipment and capacity. In total, 7,473 inpatient beds are prepared for isolating coronavirus patients, out of these 1,347 (18%) are ICU beds. As of early April, the bed capacity is assessed as sufficient (as of April 13, 230 patients were treated in hospitals, out of them 36 requiring intensive monitoring). Armed forces have also started to prepare camp beds and mobile facilities in case of a broader spread of the epidemic. COVID-19 laboratory testing capacity has also grown. Since the beginning of testing in January, the labs capacity has increased from 100 tests to 2,500 tests daily (see 1.5 Testing).
At the beginning of the epidemic, many hospitals reported shortages of ventilators and personal protective equipment. These emergency appeals have initiated an unprecedented stream of donations in Bulgaria. Ventilators, PPE, disinfectants and pharmaceuticals are donated directly to hospitals or the MoH. Only for two weeks, companies and citizens donated more than EUR 1.7 million to the Ministry for essential supplies (the amount donated to the hospitals is not included).
The government has implemented several measures to mitigate shortages, including:
• additional transfer to the budget of the Ministry of Health intended for prophylactic and anti-epidemic measures;
• ban on the export of PPE, quinine-containing drugs and disinfectants;
• waiving VAT and duties on essential supplies of medical goods and equipment;
• initiating central procurement of PPE, lab testing kids and ventilators;
• taking into use medical supplies and PPE stored in the state emergency stockpiling.
Besides, municipalities have transferred funds to municipal hospitals, intended for purchasing medical equipment. Many private companies have redesigned their manufacture and started to produce face masks and shields, different respiratory protective devices, medical gowns and disinfectants. Part of the production has been donated to the MoH, hospitals, municipalities and other involved authorities. At the beginning of April, two private companies exported food products to the United Arab Emirates and Bulgaria received 15 tonnes of medical supplies, which were donated to the MoH.
The stock of essential medicines is also assessed as sufficient. A domestic pharmaceutical company is ready to start production of chlorichin phosphate within a few days.
In general, the measures to contain the spread of COVID-19 transmission are apprised as timely and efficient, as ensuring enough time to prepare the health system for the epidemic outbreak.
As of April 22, 281 patients or around one-third of all active COVID-19 cases were treated in hospitals, out of these 40 patients requiring intensive care. The number of patients requiring hospital treatment is still far below the COVID-19 designed bed capacity. Wards for coronavirus patients have been prepared in every public hospital throughout the country except in specialised oncological hospitals (so-called comprehensive oncological centres), as well as in many private inpatient health care establishments.
Up to mid-April, the government imported and delivered a considerable stock of PPE, including face masks, gloves and medical gowns. As of April 22, the supply of PPE was assessed as sufficient for hospital personnel involved in the treatment of coronavirus patients. Additionally, a new procurement for PPE has been initiated. However, some laboratories reported difficulties in the supply of reagents for PCR tests.
From May 10 onwards, a positive trend toward continuous decline in newly confirmed COVID-19 cases is being recorded. Moreover, the daily number of recovered exceeds the number of newly registered coronavirus patients. Under 300 patients are treated in hospitals, out of these less than 30 patients requiring intensive care. Based on these positive trends, some clinics transformed into COVID-19 wards, especially in the capital have restored their common activities. Coronavirus patients are admitted to specialized infectious wards, which capacity is assessed as sufficient. However, this is possible only in the capital and other district cities with established facilities for infectious diseases and limited spread of infection.
The relaxation of restrictive measures relieved pressure on the economy and social system but also led to a considerable increase in registered COVID-19 cases, which put tension on the health system. As of August 22, out of 4,300 active cases, 734 patients were being treated in hospitals, including 73 requiring intensive care.
In August 2020, the Ministry of Health announced the establishment of a Centre for Coordination at the Hospital for Infectious Diseases in the capital, which is the most affected region in Bulgaria. The Centre will admit patients with COVID-19 or suspected infection from the district for triage and refer ambulances to appropriate health care establishment. This was intended to improve the coordination between the hospitals involved in the treatment of COVID-19 patients.
Despite the steep rise in COVID-19 cases in July and August 2020, the government did not plan to reimpose stricter measures. According to the health authorities, the rapid early response allowed the health system to be prepared for the pandemic, meaning the system can endure the pressure of increased cases requiring hospitalisation. The physical capacity has been assessed as enough for the current spread of the virus. The Minister of Health has declared the readiness to designate more than 8,000 beds for COVID-19 patients (out of which 1,100 are in intensive care) if newly registered cases would exceed 350 daily. According to the Minister, the stockpiling of PPE and disinfectants would be sufficient for several months at the rate that COVID-19 was spreading.
Additional efforts to expand testing capacity have been made, and thus, the number of tests performed daily has significantly increased. However, there is criticism that Bulgaria still lags behind many EU and neighbouring countries regarding the number of PCR tests performed (52,150 tests per one million residents as of August 22).
As the newly registered cases continued to rise in October, some hospitals reported shortages of beds designated for COVID-19 patients and thus redirected to a hospital in another district. On October 23, an order of the Minister of Heath set new requirements for inpatient health care establishments: Every hospital in the districts with an incidence above 120 cases per 100,000 inhabitants must earmark at least 10%, and districts with an incidence between 60 and 119.9 cases per 100,000, 5% of the bed capacity for COVID-19 patients. The requirements were in force for all hospitals regardless of their ownership, as well as for the complex oncological centres. Meanwhile, the elective surgeries and planned hospital admissions were suspended. The Association of Private Hospitals opposed this decision, claiming that some private hospitals are not able to comply. Instead of ensuring bed capacity, smaller private hospitals have committed to redeploy medical specialists to public hospitals. The COVID-19 wards have been already organised in several private hospitals in Bulgaria, however.
At the end of October, the country was approaching almost 3,000 infected per day, the incidence exceeded 220 per 100,000 people, and the number of hospital admissions of COVID-19 patients was growing by a third every week. The bed capacity throughout the country was further increased, providing additional beds for COVID-19 patients. Additional wards in several large hospitals were transformed for COVID-19 patients only, but this measure created discontent among patients with chronic diseases.
Due to the surge in newly registered cases and the steep increase in hospital admissions, on November 11, the Minister of Health ordered further measures to increase bed capacity. In every district, at least 20% of beds available in hospitals and complex oncological centres must be reserved for patients with primary or concomitant SARS-CoV-2 infection. The directors of the respective RHIs are responsible for the implementation of this requirement, determining the hospitals and number of beds for COVID-19 patients.
The government approved a transfer of BGN 50 million (EUR 25.6 million) which has to support inpatient health care facilities providing more than 50% of their bed capacity for treatment of COVID-19 patients. Additional funds were earmarked for establishments of COVID-19 zones (medical offices) to the outpatient medical centres designed for diagnostic and consultations of patients with flu symptoms. BGN 15 million (EUR 7.7 million) are to be spent on delivery of antibody tests for the COVID-19 zones.
In October and November 2020, the rising numbers of COVID-19 cases overloaded not only hospitals but also the emergency care system. In the large district cities, the Centres for Emergency Care were overwhelmed with emergency calls, and severe delays in response were reported. The Ministry of Health purchased new ambulances to alleviate the pressure of the emergency care system; additional vehicles from the Ministry of Internal Affairs were equipped to assist the emergency services in the capital where the highest incidence in the country was recorded.
In October, the government decided to spend an additional amount of BGN 2.1 million (EUR 1.07 million) for delivery of medicines for inpatient treatment (Remdesivir). Meanwhile, a shortage of other drugs, which are used for the therapy of COVID-19 patients, was reported mainly due to unnecessary stockpiling with drugs for home treatment.
In November, the government approved additional funding to the budget of the Ministry of Health intended for delivery of 1.5 million antigen tests and purchase of medicines (Remdesivir) for hospital treatment of COVID-19 patients.
In December 2020, the Minister of Health imposed restrictions on the export of some drugs used for hospital treatment of COVID-19.
The Council of Ministers allocated an additional BGN 125 million (EUR 63.9 million) to purchase COVID-19 vaccines, thus bringing the total amount earmarked for vaccines to BGN 305 million (EUR 155.9 million).
Links and sources:
Informational Portal for COVID-19; https://coronavirus.bg/
Council of Ministers; http://pris.government.bg/prin/default.aspx
Eurostat (2020). Hospital beds. https://ec.europa.eu/eurostat/databrowser/view/tps00046/default/table?lang=en
Ministry of Health; https://www.mh.government.bg/bg/
National Centre of Public Health and Analyses. Healthcare statistics. Sofia, 2019; https://ncpha.government.bg/images/___NCPHA/__Publications/_Statistics/HealthcareStatistics_2019.pdf