Health Financing System in Bulgaria View larger

Health Financing System in Bulgaria

This monograph focuses on theoretical concepts and practically applied assessments of the development of the healthcare financial system and its reform over the last 30 years – one of the most important topics in the field of the healthcare economy. It is the result of eighteen years of scientific and expert work.

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Author(s): Antoniya Dimova
Publisher: Varna Medical University Press
Year of publication: 2018
ISBN: 978-619-221-178-3
How to reference: Dimova, A. Health Financing System in Bulgaria. Varna, Varna Medical University Press, 2018. 175 p.

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The monograph “Health Financing System in Bulgaria” by Antoniya Dimova is a remarkably extensive theoretical and systematic study of the financing of the healthcare system that contributes to the development of Bulgarian healthcare economics. Antoniya Dimova is a representative of the strong Varna scientific movement of members of the Health Economics and Management Department, with excellent training and international experience.

Within its structure, the monograph encompasses an introduction, four chapters, a conclusion and a reference list of around 180 sources, most of which are written in English. The advantage of this monograph is that different illustrative tools are used – figures, charts and tables.

The first chapter presents the main theoretical concepts and aspects of healthcare financing – accumulation of funds, pooling them into a common fund, funds distribution by types of activities, levels and structures, and purchase and provision of health services. The second chapter is devoted to the historical development of the health financing system in Bulgaria since its genesis in 1906, with the introduction of the first form of social health insurance. Applying the historical approach, Antoniya Dimova defines different stages in the development of the system. The third chapter presents the main players in the financing system – the NHIF, Ministry of Health, professional organizations and consumers contributing with regulated and unregulated payments.

The most interesting parts, with the author’s assessments and suggestions, are the fourth chapter and conclusions, focused on diagnosing the problems of the health financing system and addressing possible approaches for solutions. The author compares the two most important issues of health system financing in Bulgaria – resource deficiency and inefficient use of these resources.



Review by Prof. Stefka Koeva, Medical University “Prof. Dr P. Stoyanov” – Varna

Review by Prof. Dr Evgenia Delcheva, University of National and World Economy, Department of Public Administration

List of Abbreviations

List of Tables

List of Figures




CHAPTER 1: Understanding health system financing

Theoretical framework and concepts

   Revenue collection

   Pooling of funds

   Allocation and purchasing/ provision of services

Role of financing for achieving health system goals

Assuring access

Guaranteeing quality

Principles and design of the system

CHAPTER 2: Health financing in Bulgaria: evolution of the modern system

Background: pre- 1989 legacy and the need to change

   Health insurance system 1918-1951

   Centralized government system 1951-1989

   The need to change

First stage of changes: 1990-1997 health system financial collapse and the introduction of a new source of revenue

   Political and socio-economic environment

   Reforming the system: essential changes

   Characteristics of health system financing

   Emerging problems

Second stage: 1998-2001 radical reform – establishment of the health insurance system

   Political and socio-economic environment

   Reforming the system: radical changes

   Health expenditure and financial flows

   Continuing and emerging problems

CHAPTER 3: Architecture of the health financing system

Players in the system

   Actors in health system financing: the power to decide

   Participants in health system financing: the right to agree

Health expenditure: trends and comparisons

Financial flows

   Pooling of funds – sources of revenue


   Payment mechanisms

VHI: still outside of the system

   VHI expenditure

   VHI market reform

   VHI market role and size

CHAPTER 4: Diagnosing the system

Financial stability

   Sustainable financing versus sustainable financing problems

   Policies aimed to achieve financial stability of the system

Fairness and financial protection

   Solidarity and equity in financing

   Financial protection


CONCLUSIONS: Moving forward

Setting back principles into practice

   Restoring solidarity

   Restoring the self-governance of the NHIF

   Introduction of contractual relations among equal partners

Value-based decisions


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