The GOVERNANCE of the health system with regard to COVID-19 relates to pandemic response plans and the steering of the health system to ensure its continued functioning. It includes emergency response mechanisms, as well as how information is being communicated, and the regulation of health service provision to patients affected by the virus.
A National Plan of the Republic of Bulgaria for Influenza Pandemic Preparedness (available at: http://www.strategy.bg/StrategicDocuments/View.aspx?lang=bg-BG&Id=366) has been in force since 2006. Although it is aligned along epidemiology, clinical manifestation, diagnostics and treatment of flu pandemics, the anti-epidemic measures, communication, and responsibilities in implementing the plan are suitable for each case of pandemics. Anti-epidemic measures in the plan include all that have been implemented in the COVID-19 pandemics such as measures: (1) for patients (home and in-hospital treatment and isolation depending on severity of the case and risk of complications, wearing facial masks to protect contact persons); (2) for contact persons (searching for contact persons, epidemiological study and conducting medical surveillance, home isolation, wearing facial masks, and travelling restrictions); (3) other measures (suspending maternity and child consultations, prophylactic check-ups, vaccinations, and planned hospital admissions, suspending school attendance, travelling and public gathering restrictions, wearing masks on public places); (4) disinfection. The overall organisation and coordination on the plan implementation is assigned to a National Pandemic Committee (NPC), chaired by a vice-premier appointed by the Premier and the Minister of Health as a vice-chair. The NPC includes the deputy-ministers of internal affairs, finance, defence, labour and social policy, transportation, the chief state sanitary inspector, the directors of the MoH’s directorate “Protection and Control of Public Health”, the NHIF, the National Veterinary Service, the National Center for Infectious and Parasitic Diseases, the Institute of Microbiology of the Bulgarian Academy of Science, and the national consultants in epidemiology, virology and infectious diseases. The plan defines the healthcare establishments in the country assigned to admit and treat patients and envisages preparation of regional pandemic response plans.
Despite the existence of this plan, its governance was not put into practice in the current COVID-19 situation, for which the Government was criticized by experts and the public.
A National Operations Headquarters (NOH) was established through an order by the Prime Minister on February 26 to organise, coordinate and monitor all actions of competent authorities in preventing the spread of COVID-19, as well as to collect, summarise and analyse information related to the spread of COVID-19, and to inform the media and the public. The NOH is led by the Head of the Military Medical Academy. In general, the NOH has mainly advisory function to the Council of Ministers and the national and regional health authorities. Based on the recommendations by the NOH authorities issue orders for implementing anti-epidemic measures.
On March 24, a Medical Expert Council to the Council of Ministers was established with main task to prepare algorithms and guidelines for diagnostics and treatment of COVID-19 patients. The Council functioning was terminated two weeks later due to conflicts with the NOH and critics from the medical society.
The MoH and its 28 regional branches – the Regional Health Inspectorates are responsible for implementing anti-epidemic measures. RHIs maintain lists of all individuals under quarantine at each district based on an ordinance by the Minister of Health from March 17. All COVID-19 cases are subject to compulsory registration, notification and reporting following the rules of the ordinance on registration, notification and reporting of infectious diseases from 2005. RHIs report each new case to the MoH immediately and send summarised daily and weekly information to the National Center for Public Health and Analyses and the National Center of Infectious and Parasitic Diseases respectively. The center reports weekly to the European Centre for Disease Prevention and Control. Laboratory confirmation of cases is carried out in laboratories listed in an ordinance by the Minister of Health from 25.03.2020, supplemented on April 10.
A centralised National Information System to combat COVID-19, developed on a voluntary basis by several Bulgarian IT-companies, was introduced through an ordinance by the Minister of Health on April 6. The system consists five modules: informational web-portal for citizens and employers, mobile application for citizens’ health status reporting, registers of people under quarantine and confirmed cases, software for analyses and prognoses, geographical maps for data visualisation. Citizens, healthcare providers and the national and local authorities have different access to these modules. Responsibilities of the RHIs, healthcare providers and laboratories for unloading information to National Information System are defined through the ordinance. The system sends to the GPs automatically generated e-mails for the diagnosed and quarantined persons listed in their patient lists for surveillance.
The one-month state of emergency, which was introduced on March 13 and later extended to May 13, was terminated and replaced with an „emergency epidemic situation“ from May 14 to June 14 based on amendments of the Law on Health. This allowed the Minister of Health to issue orders on anti-epidemic measures, including compulsory isolation, treatment and quarantine, suspension of activities in other sectors, ban on entering the country, and public gathering, regardless the end of the state of emergency. All anti-epidemic measures, which were in place during the state of emergency, are currently subject of 4 orders by the Minister of Health.
The amendments of the Law on Health allow the Council of Ministers to declare “emergency epidemic situation” upon a suggestion by the Minister of Health, and the Minister of Health to issue orders on a broader range of anti-epidemic measures upon suggestion by the Chief State Sanitary Inspector.
The emergency epidemic situation, which replaced the state of emergency in May 2020, was extended every 15 days between 15 June and 31 August 2020 and monthly afterwards through Council of Ministers’ decisions. At the end of November, it was extended to 31 January 2021.
After the initial highly centralized approach to combat COVID-19 in the spring and the subsequent easing of measures at national level, a decentralized approach was taken in autumn, when the number of cases started to increase rapidly. Regional operational headquarters and local authorities were granted the rights to apply measures according to the specific situation in their regions (for more details, see 1.2 Physical distancing), however only a few regional authorities imposed stricter measures. Thus, the increase of the daily registered new cases was once again accompanied with an increase in centralized decision-making through the introduction of separate restrictive measures at national level in October and November to the order of completely closing kindergartens, schools, universities, restaurants, shopping centres and terminating sport and cultural events and some other measures by the end of November.
Meanwhile, in the second half of November two new deputy ministers of health were appointed to support implementation of the COVID-19 anti-epidemic measures.
At the beginning of December 2020, the Council of Ministers approved a National Pandemic Preparedness Plan following the Parliament’s decision at the end of October to update the 2006 National Plan for Influenza Pandemic Preparedness. In contrast to the 2006 plan, the new one includes only basic guidelines for organization and action in the case of a pandemic, suggesting a more comprehensive approach to managing and counteracting the adverse health, economic and societal consequences associated with any kind of widespread contagious disease. The plan sets requirements for coordination between different sectors and administrative levels in the country and for defining responsibilities at each stage of the pandemic. It envisages participation of both public and private sector partners in designing anti-pandemic measures as well as coordination between local authorities and the non-governmental sector for serving a large number of patients and providing social services.
In addition, a national COVID-19 vaccination plan was approved by the Council of Ministers in the beginning of December. Vaccination is going to be on a voluntary basis and free of charge for the citizens. The plan includes five stages of implementation, prioritizing population groups that are going to be vaccinated at each stage as follows: 1. medical staff (expected number 243,600 people), 2. patrons and personnel of the social institutions (such as care homes for the elderly), teachers and mink farm workers (112,080 people), 3. employees involved in maintaining the functioning of basic public life activities, such as police officers, 4. elderly people at and above 65 years of age and chronically ill patients (1,800,000 people), and 5. vulnerable groups with a high epidemiological risk of infection related to their living conditions and lifestyle. Responsibilities for implementation of the vaccination plan have been assigned to the National Vaccination Headquarters, established specifically for the purpose and chaired by the Director General of the Bulgarian Red Cross. The country is divided to six regions in regard to vaccine distribution and organization/planning of the vaccinations. In addition to the existing healthcare providers that are going to be involved in the vaccination process, the plan envisages the establishment of special settings and mobile vaccination teams. Financial resources will be assured for all activities including monitoring of the vaccination coverage and studies on immunological effects of the vaccines.
Sources and links:
Ministry of Health orders regarding COVID-19; https://www.mh.government.bg/bg/informaciya-za-grazhdani/informaciya-otnosno-noviya-koronavirus-2019-ncov/
Unified Informational Portal for COVID-19; https://coronavirus.bg/