Bulgaria is not an exception to the general trend in Europe, towards an ageing population, but are Bulgarian society and the national healthcare system ready to respond adequately to the trends?

According to the latest census held in 2001 the population of Bulgaria is approximately eight million (7,977,646). In comparison with the previous census of 1992 this represents a decrease of 510,000. For less than a decade the number of people aged 65 and above has increased by 150 000, and amounts to 16% of the population. If this trend continues, in the coming decades, older people are forecast to constitute the greatest part of the population.(1)

The social structure
Family and intergenerational ties count among the essential factors for the social construction of ageing in Bulgaria. Multigenerational family structure is still characteristic of the country. There are a significant number of young couples who live with their parents. In fact, 42 % of widowed or unmarried older people in 1992, lived in the home of one or more of their children. In comparison, in Finland, four fifths or more of married elders live alone with their spouse, and two thirds or more unmarried elders live alone.3 There are two reasons for this phenomenon in Bulgaria. Firstly, the majority of older people in Bulgaria are economically inactive, so they are dependent for economic survival on either family or on their own savings or pensions. Among the many hardships that came with Bulgaria’s transition to a market economy, were inadequate pensions. Most pensioners in Bulgaria are not financially independent. A second reason is the limited institutional capacity in Bulgaria. According to the figures dating back from 1992 only 0.4 per cent of older people in Bulgaria lived in an institution. By contrast, ten years earlier 5 per cent or more of the older population in countries such as France, Great Britain, Denmark or Norway did not live in private households.(2, 3) Bulgaria has a severe shortage of residential and nursing homes of good quality, that can meet the social, physical and clinical needs of older people in terms of both privacy and dignity.

The types of chronic sickness suffered by older people in Bulgaria are wide ranging. The most commonly reported conditions in 2001 among those aged 65 and more, were circulatory disease, stroke and heart attack, diabetes and its complications, cataract, and musculoskeletal ailments like arthrosis, arthritis, and osteoporosis.

Balkan stroke epidemic
Being a neurologist I will focus attention on stroke, that is so common in Bulgaria that it has been described as “the Balkan Stroke Epidemic”(7). The mortality rate from Stroke in Bulgaria is 265 in 100,000 and it is three times higher than in the EU (WHO, 2002). According to the statistics of 2001, 3.1 % of the surveyed men and 2.2 % of women have survived a stroke. One third of them were aged 45 to 65, e.g. in the economic active age(5).

Several studies on the risk factors for stroke have been conducted in Europe, including Bulgaria. Data shows conventional risk factors cannot explain the Balkan stoke epidemic. If factors such as hypertension, blood cholesterol levels, diet, alcohol consumption, and smoking were responsible, Bulgaria should not have more strokes than the rest of Europe(7). The answer to the extremely high morbidity of cerebral vascular disease and to the poor health of Bulgarians as a whole, and of older people in particular, relates to another dimension that is extremely difficult to measure, namely the delivery of the health care.

Delivery of health care
Bulgaria has embarked on fundamental reform of its health care system in the hope of improving its relatively poor health status indicators and in an effort to use available resources more effectively. Despite the recent significant changes, the Bulgarian health care system is fraught with controversy. On the one hand the total health expenditure as a percentage of GDP is two or three times lower than in the developed countries; on the other hand the number of physicians is relatively high - 344 per 100,000 (France- 330, UK – 164)(2). The high number of physicians in Bulgaria does not guarantee equal access for all social groups to health care. One of the most affected social groups are pensioners.

Although every Bulgarian citizen is free to choose a general practitioner/dentist and to change him or her every six months if s/he so desires, the access can sometimes be limited by the financial ability to pay the co-payment for every visit. If pensioners’ incomes are taken into account this co-payment is a serious financial burden on pensioners, who visit health care providers more often than any other group for drug prescribing, consultations with a specialist and diagnostic examinations.

In Bulgaria the age distribution of the urban-rural population also accentuates this problem. In 1998 older people constituted 32 % of the rural population(1). GPs and specialists prefer urban living and the concentration of health care establishments there is higher than in rural areas5. So access is a particular problem in rural areas where poor transport and high levels of poverty deter older people from seeking health care.

Access to drugs
Older people are also affected by the financial instability of the hospitals, which manifests in varying and often poor quality medical care. Being unable to pay for consumables, medicines and some examinations, many people refuse hospital treatment even when their condition demands it.

Access to drugs is another topical issue. Paying for health care and drugs reduces resources available for food and other basic living expenses. Even if pensioners are entitled to use reimbursable drugs, not all the vital drugs are listed as such. Furthermore, pensioners are not exempt from the co-payment charge made on the difference of the “reference price”. In January 2002 the government introduced Value Added Tax and this led to an increase in the prices of all drugs, and of the co-payment. This naturally hit vulnerable groups, including pensioners, very hard.

Special needs
The lack of awareness that older people are a specific group with particular features and special needs contributes to many of the problems, and it is not surprising that geriatrics does not exist as a formal specialty in Bulgaria. The responsibility for older people’s health is squeezed between GPs, specialists in internal medicine, neurologists, and psychiatrists. The medicine is “organ” focused without a systematic or holistic approach. There is an emphasis on the care of acute conditions, thus long-term treatment and rehabilitation are heavily under-resourced and largely neglected, particularly in some regions of the country.

Although the reform of hospital health care included the establishment of a number of hospitals for chronic diseases and rehabilitation, these are unevenly distributed around the country. In a big community such as Varna, the third biggest city in Bulgaria, the only specialised rehabilitation hospital was closed without establishing a viable alternative. Hence many older people and their families are doomed to struggle alone with chronic illnesses and long-term disabilities.

Developed and Developing countries
Dr Alex Kalache of the World Health Organisation identified the global contradiction that “the developed world became rich before it became old, and developing countries are becoming old before they become rich”. Bulgaria endures all the hardships of being an economically disadvantaged country with an aging population.

Dr Mariana Dragoeva-Bozhinova
Neurologist, Bulgaria
and BGS member

References:

1. National Statistical Institute, Census 2001
2. Atlas of health in Europe, World Health Organization, 2003
3. Susan De Vos, Gary Sandefur, Elderly Living Arrangements in Bulgaria, the Czech Republic, Estonia, Finland, and Romania, Center for Demography and Ecology, Department of Sociology University of Wisconsin-Madison.
4. Updating of pensions in 2003, National Social Security Institute.
5. Public Health Statistics, Bulgaria, Annual, Ministry of Health, National Centre of Health Informatics, 2001.
6. National Statistics, UK, 2001.
7. The Balkan Stroke Epidemic: the case of Bulgaria, David Bresh, M.D., Mount Sinai Hospital, New York, 1999.