Policy responses for Bulgaria - HSRM


Policy responses for Bulgaria

4. Paying for services

Adequate funding for health is important to manage the excess demands on the health system. This section considers how countries are PAYING FOR COVID-19 SERVICES. Health financing describes how much is spent on health and the distribution of health spending across different service areas. The section also describes who is covered for COVID-19 testing and treatment, whether there are any notable gaps (in population coverage and service coverage), and how much people pay (if at all) for those services out-of-pocket.

4.1 Health financing

Health financing dedicated to combat COVID-19 pandemic is provided through transfers from the state budget and Operational Programs to the MoH’s budget, transfers form municipal budgets to hospitals, and donations. Special conditions for paying healthcare providers during the crisis have been assured by the NHIF within the existing budget for 2020.

As of beginning of April, the MoH received more than €26 million dedicated to COVID-19 from the state budget, Operational Program "Regions in Growth", and donations. At the same day when the first COVID-19 cases were registered in Bulgaria, the Government approved transfer of BGN 7 million (near €3.580 million) to the MoH’s budget for prophylactic and anti-epidemic actions and effective response to the COVID-19 epidemic situation (Decree №40 from March 8). The funds are provided at the expense of a contingency and emergency reserve in the 2020 State Budget. In addition, the share of the 2020 State Budget reserve which can be used for prevention activities to reduce the risk of disasters was increased from 15% to 30%.

At the end of March, BGN 15 million (near €7.7 million) were reallocated within the Operational Program "Regions in Growth". The overall approved funding on the project "Fighting COVID 19" with the MoH as beneficiary is BGN 40 439 291,10 (€20676280 million). The funds are going to be used for the purchase of medical equipment, medicines, tests, protective equipment and clothing, investments in eHealth measures, disease prevention, and public awareness measures, as well as for ensuring access to healthcare for vulnerable groups.

A significant source of funding dedicated to combat COVID-19 is donations. Donations to the MoH from companies and citizens as of 3 April 2020 amount to BGN 3 384 711 (€1730575). Additional BGN 253 496 (€129,610) were received through the Donors Message Service (DMS). Donations flow directly to municipalities and hospitals as well. A private laboratory is starting free PCR testing of medical professionals who work in public hospitals treating COVID-19 patients.

As an attempt to decrease financial pressure over the health system financing, the Government approved a request to the EC for authorization to apply duty and VAT relief on imports of medical goods related to the fight against COVID-19 on March 25.
On April 6, the NHIF, the Bulgarian Medical Union and the Bulgarian Dental Union signed supplement to the National Framework Contracts for medical and dental care concerning payment to healthcare providers in the condition of COVID-19 pandemics. Healthcare providers whose activity have contracted due to the state of emergency will be paid up to 85% of their expected income regardless of the actual activity.

All medical specialists and other healthcare personnel who provide services for COVID-19-positive patients receive additional monthly payment of BGN 1 000 (approx. € 511) provided by the MoH through the Operational Program “Regions in Growth”.

Municipalities support the healthcare system and citizens by additional funds transfers to the municipal hospitals and donations, rent reliefs for healthcare providers, as well as local business, which use municipal property, by providing disinfectants for the common areas of residential buildings and masks, food, and additional social services to elderly and people under quarantine.  Some municipalities established special funds to support families with temporary difficulties due to the COVID-19 crisis.

In July and August, the government approved several transfers to the MoH’s budget, which were intended for the purchase of medical equipment and ambulances, additional subsidies for hospitals in remote areas and a salary increase for health professionals. Additional funds were appropriated for prophylactic and anti-epidemic measures against infectious diseases, as well as for increases of payments for health services, subsidised by the MoH (such as psychiatric care). Amendments to the Law on Healthcare Establishments allows the Ministry to subsidise hospitals for maintaining clinics and wards for infectious diseases in the case of an epidemic. For this purpose, BGN 9.6 million (approx. EUR 4.9 million) has been set aside to ensure the readiness of public hospitals to admit COVID-19 patients.
On August 14, the NHIF, the Bulgarian Medical Union and the Bulgarian Dental Union signed annexes to the National Framework Contracts for a 10 percent rise of payments for health services in outpatient and inpatient care, as well as dental care services. The increase was meant to cover the additional costs for implementing measures against COVID-19. The price of the clinical pathway designated for hospital treatment of COVID-19 patients has increased twofold, as up to BGN 126 million (approx. EUR 64.2 million) will have been allocated to the NHIF’s budget to cover the additional expenditures by the end of this year.

Further transfers to the MoH’s budget, approved by the government, include:
• BGN 16.2 million (€8.3 million) for provision of Veklury (Remdecivir) for treatment of COVID-19 patients (BGN 2.1 million in mid-October and BGN 14 million in the beginning of December)
• BGN 6.4 million (€3.3 million) to supplement the budget of the Emergency Support Instrument (ESI), which provides better access for Bulgaria to necessary vaccines (mid-November). This amount is included in the BGN 140 million (€71.6 million) dedicated to COVID-19 vaccines.

Additional BGN 80 million (€ 40.9 million) coming from the EC REACT-EU, have been allocated to the OP “Human Resource Development” in mid-November for providing additional remuneration to the first-line medical and non-medical staff, ensuring safe working conditions and improving the working environment.

Additional payments to GPs and specialized care providers for working with COVID-19 patients were introduced starting from the 1st of November. The NHIF pays GPs BGN 1000 (€511.3) per month if they take care of COVID-19 patients. Specialized medical centers with lab and imaging diagnostic structures receive BGN 30 000 (€15 339) per month if they organize COVID-19 triage teams (for more details see 3.2 Managing cases).

The approximate amount for dealing with the pandemic on the territory of Bulgaria reaches BGN 2 billion (€1.02 billion) as of end of November.

Sources and links:
Law on Healthcare Establishments, amendments, State Gazette No 71, August 11, 2020
National Health Insurance Fund; https://www.nhif.bg/
Council of Ministers; http://pris.government.bg/prin/default.aspx 
Ministry of Health – donations; https://www.mh.government.bg/bg/informaciya-za-grazhdani/postpili-dareniya-po-smetka-na-mz/ 
Committee for monitoring of the Operational Program “Regions for Growth”;  http://www.bgregio.eu/op-regioni-v-rastezh--2014-2020/komitet-za-nablyudenie-na-oprr.aspx 
National Association of the Municipalities in Republic of Bulgaria Official web-page, COVID-19 Community care; https://www.namrb.org/covid-19-dobri-praktiki-ot-obshtchinite65