HEALTH SINCE 1945: INSTITUTIONALIZATION PERIOD, PART 3

The beginning of the 70s were marked by several important events. On an international plan this is a series of conversations aimed at restraining the arms race, held between Soviet and U.S. representatives - the Strategic Arms Limitation Talks /S.A.L.T. Talks/. The first treaty was signed on May 1972 /S.A.L.T.-1/, limiting defensive anti-ballistic missile systems and agreement was reached over certain other measures. A second agreement  /S.A.L.T.-2/ was concluded in June 1979, but, it fell short of American hopes when president Carter administration found it impossible to persuade the Senate to ratify the agreement. At Geneva on 1 July 1982, Soviet and American talks were renewed under the acronym S.T.A.R.T. /Strategic Arms Reduction Talks/ - as an optimistic substitute for the discredited S.A.L.T. These S.T.A.R.T. Talks paved the way for international agreement in the 90s and continue until now.

As viewed on a national scale, the 70s brought important changes in the structure of the socialist society and in health care in particular. Let us enumerate the items on an agenda, which, will serve as a guide in the following narratives:

1. The tenth congress of BCP /1971/ gives in details the quantitative and qualitative changes in Bulgarian society. A programme is outlined for building an advanced socialist model in the country.

2. A new "Public Health Law" is voted by the sixth Common National Assembly /31 October 1973/. Important aspects of this law are, namely - prohibition of the private medical practice, adoption of a new Moral Codex of the physician, etc.

3. The process of consolidation of medical science finds its height, with, the establishment of Medical Academy as a solid, unified, scientific, therapeutical and organization-methodical complex /article № 921 from 30 April 1972/. The new institution is accredited with statutes and regulations by article № 0-9 from 7 February 1976.

So far, during this period of institutionalization, ministers of health are, namely: Dr. Angel Todorov /1971-1977/, Dr. Radoy Popivanov /1977-1987/ and Dr. Mincho Peychev /1987-1989/. At the end of year 1989, the country falls in sharp political and economical crisis. A long time regime of socialist transformation comes to an end.

We shall follow our agenda with some presentations, which, make every effort to be succinct. Main sources of information should be pin-pointed. Mention will be done, that, while the previous periods in the development of health care were scarce in materials with an international standard and here we have - in the 70s and 80s - quite an abundance from such materials. Our choice has been a matter of personal preference.    

From: ***. Health Services in Europe (2nd edition). Copenhagen: WHO - Regional Office for Europe, 1975.

 I. Background information

The People's Republic of Bulgaria, situated in the south-east of the Balkan peninsula, has boundaries with Romania in the north across the River Danube, with Yugoslavia in the west, and with Greece and Turkey in the south. Its frontier in the east is the Black Sea. Its territory covers 110 928 square kilometers and the population in 1972 was 8 576 200, i.e. 77.3 persons per square kilometer. The capital, Sofia, had a population of 877 000. The age distribution showed a preponderance of the younger age -groups: under 20 - 30.6 %; 20 to 39 - 29.3 %; 40 to 59 - 25.2 %; 60 and over - 14.9 %. For the period 1965-67 the expectation of life was 68.8 for males and 72.7 for females. The birth rate in 1972 was 15.3 per 1000 and the crude death rate 9.8 per 1000. The natural increase was 0.55 %. The infant mortality rate, which has been decreasing slightly in recent years, was 26.2 per 1000 live births.

In 1971, the main causes of death , in descending order of incidence, were: diseases of the heart, cerebrovascular diseases, malignant neoplasms and pneumonia. The communicable diseases most frequently notified in 1971 were influenza, dysentery, infectious hepatitis, measles, gonorrhoea, tuberculosis and scarlet fever.

Bulgaria is being rapidly industrialized and industry now provides more than two-thirds of the total national product. Agriculture, which is heavily mechanized, is now fully on a cooperative basis.

Education is free and is compulsory up to 14 years of age.

II. Administrative organization of the health services

The country is divided into 27 provinces ("okrugs") and, in addition, the city of Sofia has the status of province. The provinces are subdivided into urban and rural communes,

There is a unified system of public health services and the Ministry of Public Health, set up in 1944, is the central authority for health matters. Free medical care and health protection are guaranteed by law for the whole population. All medical establishments are State-owned. At the provincial level the health services are directed by the public health departments of the Executive Committees of the People's Councils.

III. Organization of medical care

The basic unit of medical activity is the hospital, which provides both curative and preventive care and is responsible for health education. The hospital physicians also work in the out-patient department and visit patients at their work and at home.

The medical services are developing rapidly, especially in rural areas, which were formerly much neglected. Every rural commune has a health service and nearly every village with a population of over 2000 has its own health service, headed by a physician, There were 1223 such centres in 1970. In smaller settlements and in the more remote localities, care is usually provided by a feldsher working under medical supervision. Each rural health centre has a dental clinic.

Rural health services receive assistance from specialists in the regional hospitals.

In 1970 there were 200 hospitals with 56 009 beds and 185 sanatoria with 16 310 beds. In addition, there were 3587 polyclinics, dispensaries and other out-patient establishments, with a total of 7362 beds. At the end of 1970 there were 9.4 beds per 1000 inhabitants. Of these facilities, 15 rural polyclinics, 181 rural health services, 1127 rural health centres, 1866 health centres directed by feldshers and 903 rural maternity homes, with a total of 3464 beds (including 2569 maternity beds) served rural areas. Industrial workers receive specialized medical care over and above that provided by the general medical service. Big industrial plants have medical establishments of their own: hospitals, polyclinics, prophylaxis centres, night sanatoria, rest homes, etc.

IV. Organization of preventive services

The standard of hygiene in both urban and rural areas is steadily rising. Guided by the central medical authorities, co-operation between the local authorities and the population is giving good results. Sanitation and epidemiological stations provided with laboratory facilities play a very important role.

Towns, both large and small, and industrial centres have water supply and sewage disposal systems.

At the present time infectious diseases pose no great problem, for Bulgaria is practically free of most epidemic diseases. Although tuberculosis is becoming increasingly less prevalent, the campaign to wipe out this disease continues and the population is subjected to compulsory and systematic X-ray examinations and BCG vaccinations. Treatment for tuberculosis is free, whether in hospitals, sanatoria or at home.

Employed women are entitled to fixed periods of maternity leave, as follows: 120 days for the first child, 150 days for the second and 180 for the third. During pregnancy they are encouraged to undergo medical examinations and to follow special courses. Creches are at the disposal of all working mothers. In 1970 there were 1003 creches with 43 697 places for children.

There is well-developed school health service. Each school doctor is in charge of some 2400 children, who are organized in Red Cross groups.

Mental health dispensaries have been set up throughout the country to prevent and treat mental disorders.

Special attention is paid to health education which is directed, under the Ministry, by the Institute of Health Education in conjunction with the Red Cross.

V. Public health information and research

Research work in all major fields of public health is carried out by 12 central scientific research institutes under the Ministry of Health. Some of these institutes were recently reorganized to form a Scientific Institute of Social Hygiene and Health Organization.

VI. Supply and training of health personnel

In 1971, the breakdown of principal categories of health personnel was as follows:

16 183 physicians (i.e., 1 physician per 530 inhabitants)

3 131 stomatologists (dentists) (i.e., 1 stomatologist per 2739 inhabitants)

5 012 feldshers

2 464 pharmacists

6 016 midwives

26 381 nurses

807 physiotherapists

556 rehabilitation workers (in 1970)

3 847 laboratory assistants

886 X-ray technicians

Three schools of medicine, in Sofia, Plovdiv and Varna, offer a six-year course of training for physicians, who may receive further training at the Institute of Advanced Medical Studies, which has university status. In order to qualify as specialists, physicians must follow special courses and pass a State examination.

Bulgaria also has 17 schools for nurses, feldshers, midwives and laboratory assistants (two-year and three-year courses).

VII. Financing of health services

The cost of medical care is met, either directly or indirectly, by the State.

Fig. 1: Public Health Administration in Bulgaria

/to be continued/.