BULGARIA Istanbul, 03-05 February, Turkey HOW DATA ANALYSIS AND COLLECTION SUPPORT CIHSD IN COUNTRIES AND HOW HEALTH OUTCOMES INFORM HEALTH SERVICES DELIVERY BULGARIA Istanbul, 03-05 February, Turkey

Data collection and analyses Knowledge core element Integrated care Information Data collection and analyses Evidence based decisions

HEALTH Health policies play an important role in shaping demographic transformation Bulgaria’s rapidly aging population is expected to put pressure on public health expenditures Health status of Bulgaria population adds a sense of urgency to an already large need for health service delivery reform But the health system is not addressing the burden of disease in an efficient way

BULGARIA SITUATION The quality and the effectiveness of provided medical services are influenced by several major reasons: Lack of research and analysis of the population’s needs of the different types of medical services and respective planning of necessary resources; Primary care inefficiency, predominantly referring to GPs’ activity; Market orientation of hospitals – i.e. “induced needs” of the citizens; Increasing efficiency regarding the introduction of new and high-efficient technologies; reduced average duration of stay, increased utilization of beds, and last but not least a high turnover of the same bed; Lack of sufficient regulations in the system - medical standards, resource and investment planning, etc. Lack of well-organized information system and systematic analysis - break the link between the data at different levels of health services Different classification systems – not a real integration between them

Studies of Service Delivery Efficiency in Bulgaria Using Hospital Data – National Center of Public Health and Analyses Using health data records the researches helped illustrate efficiency issues related to some of key weaknesses of hospital system in Bulgaria The data analyzed comprises the records of each hospital stay which was reported by hospitals to the National Health Insurance Fund (NHIF) and collected by the National Centre for Public Health and Analysis between 2004 and June 2013. In total they amount more than 11 millions records. This study was developed by Técnicas de Salud in the context of a contract with the World Bank (PO#7165706).

The DATA The data was made anonymous but each patient has a unique identification number, which is identical for all his/her hospital stays in the database. Each record includes information about the patient’s demographic characteristics, diagnoses, some medical procedures performed, Clinical Care Pathway (CCP, see below for a definition) and length of stay. In addition, for each record, hospitals report a cost which is computed according to a standard methodology. It is important to note that approximately 116 variables can be recorded for each record. These records come from 275 acute and long term care hospitals

SOME RESULTS (without numbers) The fragmentation of the hospital sector translates into a large variability of the activity across hospitals. Many Bulgarian hospitals have a very low throughput, which in itself is highly inefficient. A large proportion of patients are hospitalized more than once in the year, a sign of poor effectiveness and quality of care. In Bulgaria, the database suggests that around 13.4% of the population had at least one hospital stay in the year. Referrals patterns in the study also highlight some dysfunctions and suggest that the quality and effectiveness of care might be sub-optimal.

Conclusions In sum, the hospital system does not appear very productive/ inefficient (scarce output), something that is related in broader terms to other features: a. Too large and too fragmented (reflecting that it was created in response to a different set of health issues); b. Too old, insufficiently endowed with technology (although not always the right technologies are being introduced as health care is becoming more expensive); c. Too separated from other levels of care (notably emergency and PHC services) d. Quality or effectiveness of care appear very variable across hospitals; e. Low efficiency is the key finding

Recommendations In order to address those issues, Bulgarian Ministry of Health is advised to address the following additional problems: a. Structure with excess size and fragmentation b. Imbalanced technological endowment c. Insufficient coordination of care around 20 percent of hospital discharges correspond to conditions which international standards suggest could be routinely treated on an outpatient basis e. Dubious quality f. The payment system is inadequate g. Little sensitivity to the purchasing and regulatory actions of a single payer h. Insufficient response to patients’ expectations and to evidence

The good news Some of the recommendations were taken into consideration by the Ministry of Health in: the development of the new National Health Strategy 2014 - 2020 and The new National Health Map