2009年-世界发展银行全球_Bulgaria___Improving_Quality_and_Sustainability_of_the_Health_System_11页_560kb

Summary of World Bank Policy Note: Bulgaria - Improving Quality and Sustainability of the Health System

Core Content

This policy note outlines the key challenges and reform directions for Bulgaria's health system, focusing on hospital efficiency and quality, primary health care, pharmaceutical policy, and the future development of the national health insurance system (NHIF). It also provides guidance on managing the health sector through the economic downturn.

Main Messages

• Health System Reforms: Bulgaria has made significant health sector reforms over the past decade, but substantial work remains to close the gap with the rest of the EU.
• Out-of-Pocket Spending: Bulgaria has one of the highest shares of out-of-pocket (OOP) spending in the EU, which disproportionately affects the poorest households.
• Hospital Sector Growth: The hospital sector has expanded rapidly, leading to inefficiencies and unsustainable spending. This growth has crowded out investment in primary health care and cost-effective drug reimbursement.
• Primary Health Care Weakness: Primary health care is underfunded and underperforming, with low patient trust and high referral rates to higher levels of care.
• Pharmaceutical Policy Risks: The new positive drug list increases the risk of budget overruns for the NHIF, especially in 2009, due to the inclusion of expensive drugs without effective rationing mechanisms.
• NHIF Reforms Needed: The NHIF needs to be reformed to improve its role in health financing, including better contract negotiations and a shift towards more sustainable funding models.
• Economic Downturn Considerations: The health sector requires careful management during the downturn to protect vulnerable populations and ensure system sustainability.

Key Policy Areas

1. Rationalizing the Hospital Sector and Improving Quality of Care

• Sector Growth: The number of hospitals and hospitalizations has increased significantly, with high average length of stay and low bed occupancy rates compared to EU standards.
• Efficiency Challenges: The fee-for-service model led to overutilization and high re-admission rates. Annual budget ceilings introduced in 2007 helped reduce hospitalization growth but are not yet permanent.
• IT System Impact: A new NHIF IT system improves monitoring of medical claims and can help reduce inefficiencies, but savings may erode over time.
• Master Plan: A master plan is in place to optimize hospital capacity, addressing excess acute care beds, too many specialized hospitals, and low-case-volume facilities.
• Ambulatory Surgery: Increasing ambulatory surgery rates could save millions of bed days annually and improve patient outcomes.
• Quality Assurance: Licensing and accreditation systems are underutilized and lack credibility. An independent entity could be established to improve quality monitoring and link hospital payments to service quality.
• Investment Needs: Significant investment is required to improve hospital infrastructure and equipment, which are currently poor and contribute to low public satisfaction.

2. Strengthening Primary Health Care

• Underperformance: Primary care is underfunded and inefficient, with low patient trust and high referral rates to secondary and tertiary care.
• Budget Allocation: Primary care accounts for only 7.5% of the NHIF budget, much lower than in Western Europe.
• Capitation Model: The capitation payment model for primary care does not provide strong incentives for service improvement.
• Preventive Care: Primary care is crucial for managing chronic diseases like cardiovascular conditions and cancer, but it is not currently fulfilling this role effectively.
• Regulatory Changes: Revising regulatory standards to include more conditions under primary care could reduce unnecessary referrals.
• Pay-for-Performance: Implementing pay-for-performance measures in primary care is a key priority, supported by the new NHIF IT system.
• Budget Reallocation: Shifting resources from hospitals to primary care is essential for system efficiency and quality improvement.

3. Pharmaceutical Policy

• New Drug List: The new positive drug list includes many expensive drugs but lacks effective rationing mechanisms, risking the NHIF drug budget.
• OOP Spending: High OOP spending on drugs exacerbates inequities, especially for the poor.
• Prescription Patterns: Inappropriate prescribing is common due to industry marketing, and NHIF needs to monitor and incentivize better practices.
• Unregulated Procurement: Direct hospital procurement lacks oversight, including price and utilization monitoring.
• Pricing Model: The pricing approach for the new drug list reduces competition among manufacturers.
• Contract Models: Introducing more flexible, non-price-based contracting models could help improve pharmaceutical market dynamics.

4. Future Development of the National Health Insurance System

• Autonomy and Transparency: The NHIF is an autonomous agency but faces challenges in negotiating the National Framework Contract (NFC) with the Bulgarian Medical Association (BMA).
• Single vs. Multiple Payer Models: Both single and multiple payer models could be viable, but success depends on proper implementation and oversight.
• Health Contribution Rate: The health contribution rate was increased to 8% in 2009, with some funds allocated to reserves to buffer against economic downturns.
• Insurance Coverage: A significant portion of the population (especially the poorest) is not insured, and measures to address this should be based on solid data.

Economic Downturn Management

• Protect Health Spending: Health spending should be safeguarded to prevent adverse impacts on the poor.
• Stabilize Drug Budget: Introducing waiting lists for high-cost drugs and ensuring adequate funding for nationally procured drugs could help stabilize the drug budget in 2009.
• Use NHIF Reserves: NHIF reserves can be used to absorb budget shocks, but should be managed carefully.
• Price Controls: Holding prices constant in 2010 and adjusting CCP/DRG prices for high-volume services may be necessary.
• Avoid Budget Cuts: Cuts to primary care and drug budgets should be avoided to maintain essential services.
• Hospital Closures: While not a simple solution, the downturn provides an opportunity to initiate hospital efficiency reforms and prepare stakeholders for structural changes.

Conclusion

Bulgaria's health system requires a comprehensive reform agenda to improve efficiency, quality, and sustainability. The focus should be on rationalizing the hospital sector, strengthening primary care, improving pharmaceutical policy, and reforming the NHIF. During the economic downturn, protecting health spending and stabilizing key budgets will be critical to maintaining access to care for vulnerable populations.