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”Technology is not enough”

Bulgaria: Experience with the transition process in the health sector

Von Christine Rutschmann & Assen Pacheijeff / Schweizerisches Rotes Kreuz SRK

The progress of the Bulgarian health care system transition has been impressive. However, there are numerous problems remaining. The transition process has shown that there is not only need for new technology, but also for know-how transfer. A Bulgarian-Swiss Project is a good illustration of this combination.

Due to dramatic changes after the collapse of the communist system, Bulgaria has got into a deep social and economic crisis which has left more than 70% of the population to live on the edge of poverty. Health services were one of the most affected components of the social security system. The morbidity and mortality rates have risen up to levels of the first half of the last century. The average life expectancy shrunk for both men and women. Calculated against GDP, the overall health expenditure has decreased to 3.2% and is lower than in other East European countries (average: 5.1%) and substantially lower than in Western European countries, where health care expenditure is approx. 8.4% of GDP on average.

Since 1999, the Bulgarian health care system has engaged in a major reform process. After the establishment of a national health insurance system, the reform process focused first on transforming former out-patient polyclinics into general practices and diagnostic centres. Today some 8’000 family doctors are providing primary medical care. They are paid on a per capita basis. There is a reimbursement scheme for drugs, and some vulnerable patient groups are fully exempted.

The reform process was not smooth, although it has been so far quite successful. However, there are still a lot of shortcomings and open questions. Many of the new general practitioners do not have an adequate training and experience. For example they are not always familiar with immunization schedules for children and adolescents. The former well organized network of school physicians was demolished in the recent years for financial reasons.

Reforming the hospital sector

However, the situation of the hospitals has deteriorated dramatically in the past five years and is now threatening the success of the whole health sector reform. Accordingly the National Health Strategy 2001-2007 addresses now problems at the hospital level. The most burning issues in Bulgarian hospitals are:

a. Insufficient budget allocation: Frequently patients have to pay by themselves for drugs and for basic consumables, such as wound dressings and disinfectants, because the hospital has no money.
b. Squandering and financial mismanagement of the hospital administrations.
c. Corruption in the hospitals: Staff is trying to compensate their low salaries by requesting ‘under the table’ payments from the patients.
d. Exodus of highly skilled specialists and nurses: staff leaves public facilities either for the local primary care sector or for other countries.
e. Last but not least, poor quality of the services provided in the hospitals and in particular inadequate hygienic conditions which cause a high risk of hospital acquired (nosocomial) infections (NI). A large part of the problems associated with NI arise from the lack of information, lack of adequate basic and continuous training of medical and paramedical staff in the field of nursing and hygiene standards and a lack of treatment guidelines. There are also loopholes in the quality assurance and control system.

The practical implementation of the new Strategy for Restructuring of the Hospital Sector has major challenges. The restructuring of the 300 hospitals in the country is underway and coincides with the introduction of an obligatory 5-year accreditation scheme. The credit points assigned to a particular hospital provides a basis for the funding allocation of the health insurance. In addition treatment costs in the hospitals are covered according to specified clinical pathways. New medical standards in all basic and interdisciplinary therapeutic areas have been introduced, including quality assurance measures at all levels in the health care system. Basic training for all healthcare workers has been harmonized with the training requirements in other European countries and a credit-points-based system for continuous medical education has been established.

International cooperation and reform

The Bulgarian health care reform provides a lot of opportunities for development and cooperation projects. Such opportunities have already been seized by a number of international institutions and organizations, like the World Bank (WB), the World Health Organization (WHO), the US Agency for International Development (USAID), the Swiss Agency for Development and Cooperation (SDC). One of the WB-sponsored projects provided equipment for the new general practitioner clinics. The World Health Organization (WHO) supported several projects for epidemic control and prevention.

In addition and more recently several projects have been supported by various national and foreign non-governmental organizations (NGOs), like the Swiss Red Cross, Medecins Sans Frontiers, and others.

The Bulgarian-Swiss Program for Hospital Hygiene

The Bulgarian-Swiss Hospital Hygiene Program (BSHHP) is financed by the Swiss Agency for Development and Cooperation, and the Bulgarian Ministry of Health. It is implemented by the Swiss Red Cross and the Hygia-BSHHP Association, a local NGO. The program comprises three components: hospital hygiene, clinical microbiology and central sterile goods supply in the hospital. The overall goal of all three components is to harmonize the standards for prevention and control of nosocomial infections in Bulgaria with the standards that are in use in other European countries. In the long term, the program will contribute not only to a substantial decrease in hospital-acquired infection rates, but also to a qualitative improvement of the services provided in the hospitals. Thus the programme intends to establish basic surveillance standards. It will also provide information on the prevalence of nosocomial infections existing in the hospitals. The nosocomial infection rates are today varying from 0.01% up to 30% (average in Switzerland: 5-8%). The program has started in April 2002 and will cover six hospitals until the end of 2004. The results of this pilot project shall be assessed and the potential for replication at a countrywide level will be explored.

The tactics of the program with respect to the particular projects is based on following activities:
Clinical Microbiology Component: Training courses will be carried out to promote modern methods for microbiologic identification and diagnosis. An Internet-based network for reporting, exchange and analysis of data from the microbiological laboratories will be set up and measures for standardization and external quality control will be instituted.

The Hospital Hygiene/Prevention and Control of NI Component: The development of a contemporary professional standard for hospital hygiene will be supported. Theoretical and practical training courses for hospital epidemiologists, infection control nurses and clinicians will be carried out and a new position within the infection control team in the hospital will be introduced, that is an ”infection control nurse”.

The Central Sterile Supply Department (CSSD) Component: Training courses for CSSD staff will be carried out and based on the pilot project, the concept for a ‘closed circle’ for quality assurance in the field of aseptics and antiseptics will be demonstrated.

One other important aspect of BSHHP is the building up of Bulgarian clinical mentors providing practical guidance and support to all trainees in their respective working place. Currently there are no mentors available in Bulgaria, neither nurses nor medical doctors who could fulfill this role. The purpose of the clinical mentor is to instruct and to teach students on the job while in hospitals, clinics, community and other clinical settings, to facilitate with staff in the clinical site to enable the best learning experience for the students. There might be some opposition from the medical staff as far as the nurses receiving additional continuous training is concerned. The mentors can be instrumental in defusing these tensions.

It is obvious that the program design is emphasizing the educational factor, i.e. the transfer of modern know-how. It is also a logical continuation of a former technology-transfer oriented program, which had been sponsored by the Swiss State Secretariat for Economic Affairs (seco). Thirteen regional hospitals in Bulgaria have received modern central sterile supply departments. In the final evaluation of the project in 1999, hospitals realized that their main problem was not only the absence of equipment but also the lack of adequate hygiene measures in disinfection, decontamination and lack of know-how and quality assurance. In 2000, the Swiss Development Cooperation developed with the Bulgarian partners a new project which has built on the achievements of the former seco project. The continuity of the two programs represents a good example of sustained cooperation, based on a mixture of technological and of know-how transfer and highlights the need to combine the two.

It is also representing the continuous support which Switzerland, has been providing to the Bulgarian healthcare system over the past ten years.

*Assen Pacheijeff is the coordinator of the local Project Implementation Unit of the Association Hygia for the Bulgarian Swiss Hospital Hygiene Programme. Christine Rutschmann is the responsible programme coordinator at the Swiss Red Cross, International Cooperation, for Bulgaria as well as Central-Eastern Europe and the CIS and the programme director of the BSHHP. Contact: or


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