This presentation was made by Lyubomir Kamboshev, Bulgaria, at the 2nd Health Systems Joint Network Meeting for Central, Eastern and Southeastern European Countries held in Tallinn, Estonia, on 1-2 December 2016

1. Health Care
Financing in Bulgaria
KEY PLAYERS IN DEFINING HEALTH
EXPENDITURE
Lyubomir Kamboshev
Ministry of Finance
Bulgaria

2. KEY PLAYERS IN DEFINING HEALTH EXPENDITURE
 The National Assembly, which decides on the levels of total
public spending, allocations between sectors, and within health,
the MOH and NHIF budget;
 The Government, including the Council of Ministers (COM), the
Ministries of Health and Finance as well as numerous other
Ministries and agencies;
 The National Council on Prices and Reimbursement of Medicinal
Products (the Pricing Council);
 The NHIF and its 28 regional branches, municipalities, private
voluntary insurers,
 and of course individuals who purchase goods and services –
the patients and consumers.

3. Health care system in Bulgaria
Health insured population
Covering
National Framework Contract
Collecting revenue
mechanism
Risk sharing
Healthcare purchasing
Providing services
Subsidies from state
budget
Health insurance
contributions
Health care providers
National Health Insurance
Fund

4. Focus on health financing

5. Public health expenditure as % GDP in selected
countries in 2014
Sources: WHO, NHIF accounts and authors calculations

6. Health Expenditure - Bulgaria and
Selected Countries (2014)
Sources: WHO, NHIF accounts and authors calculations
Public
Health
expenditure
(%GDP)
Total health
expenditure
(%of GDP)
Total Health
Expenditure per
Capita in US$
Out of Pocket
Expenditure as
%of Total
Health
Expenditure
Belgium 8.2 10.6 4 884 18
Bulgaria 4.6 8.4 662 44
Czech Republic 6.3 7.4 1 379 14
Estonia 5.0 6.4 1 248 21
Germany 8.7 11.3 5 411 13
Greece 5.0 8.0 1 743 35
Italy 7.0 9.2 3 258 21
Latvia 4.0 6.0 921 35
Lithuania 4.0 7.0 1 063 31
Poland 5.0 6.0 910 23
Romania 4.0 6.0 557 19
Spain 6.0 9.0 2 658 24

7. Health insurance payments in 2016
Sources: NHIF accounts and authors calculations

8. Milestones to be achieved
 Implement a technically-driven hospital rationalization plan;
 Support this implementation by genuinely selective contracting
and, as relevant, strategically selected investments;
 Encourage consolidation and streamlining in areas of high
density by merging facilities into autonomous and fully
financially accountable networks;
 Introduce DRG-based payments and maintain strong incentives
to limit volume escalation;
 Generate, collect, use and publicize information on quality to
support the rationalization process;
 Strengthen quality assurance mechanisms.

9. Financial flows between the central
budget and NHIF
Sources: NHIF accounts and authors calculations

10. Focus on health financing
Sources: NHIF accounts and authors calculations

11. Main problems affecting the financing
and management of healthcare
 The lack of competition in the market of health insurance;
 Significant amount of informal payments;
 Significant overcapacity in hospitals;
 Negotiating process with health care providers

12. Reforming Health care system: way forward
 To create conditions and incentives for the development of
voluntary health insurance;
 Options for mobilizing additional resources in the system;
 Changing the type and structure of financing mechanisms to
health care providers;
 Restructuring hospital sector;
 Direct negotiation of prices and volumes