HEALTH SINCE 1945: INSTITUTIONALIZATION PERIOD, PART 4

From: ***. Primary Health Care in the Bulgarian National Public Health System. Sofia: Medical Scientific Information Centre, 1978.

Going through exclusively difficult stages of development, Bulgarian Public Health nowadays represents a harmonious dynamic system connected functionally with the entire social and economic development of the country, and, related to all spheres of social life. The right of every citizen for good health is guarantied by the Republic's Constitution and by the Public Health Law /31 October 1973/ which rests on the basic socialist principles.

The state character of the public health is the first basic principle. As a social structure, the public health system is built, organized, financed and directed by the State and for that reason it represents and integral part of its politics. The institutional structure of the health network is built on a common hierarchical principle, compulsory for all administrative units in the country. This structural unity is an important stipulation for the even medical care distribution on the whole territory of the country, as well as, for the effective administration of public health activities.

An important characteristic of public health in the People's Republic of Bulgaria /PRB/ is its planning character. The public health plan is an integral part of the uniform national economic plan. It is created on the basis of thorough scientific researches on the alterations of the ecological system "man-environment", the incessantly changing requirements of the population for medical care, the tendencies of the health and demographic state of the country, the agglomeration of the population and the growth of the settlement systems, on the long-term prognostics for the development of productive forces, on the development of the public health resources, etc.

Prophylactics is a main tendency of Bulgarian Public Health. In the endeavor for good health the introduction of this principle is a qualitatively new and higher stage, which, can be realized only when interests of the people and the State coincide and develop in an organic unity. Essential feature of the prophylactics in the PRB is its comprehensive character. The activity sphere of the prophylactic measures is raised on a state level.

The successful social and economic development  of the country created favorable conditions for the gradual decrease of the incidence of some and the complete eradication of other infectious and parasitic diseases. Under the organizational and systematic guidance of the "Inspectorates of Hygiene and Epidemiology" with the active participation of all prophylactic and curative establishments, as well as of the population itself, for many years along a planned and comprehensive immunoprophylactics and other antiepidemic measures have been taken.

Another basic principle of public health for the Bulgarian people is the insurance of a mass accessible, free of charge and qualified medical care for the whole population. On the present stage the prophylactic, diagnostic, curative and rehabilitative measures - as well as - some of the social ones for the protection, promotion and restoration of the people's health are realized by a widely spread, hierarchical, state functioning and mutually coordinated system of health establishments covering by their activities the population of the country - as a whole - and every person individually from his birth till his death. The health structure of a higher level executes a more and more specialized activity and represents an integral part of the uniform public health system.

The basic organizational unit of public health is the team of microregional physicians. The primary health care in all its medical aspects and in some of its social ones is realized by team.

Public health in Bulgaria is build up and developed on the principle for unity of medical science and practice. This principle is realized by the wide development of the fundamental and applied medical scientific researches and by the implication of the latest scientific achievements into practice. The medical science provides the medical workers with modern methods of prophylaxis, diagnostics, treatment and rehabilitation. The insurance of scientific progress in the public health practice is a subject of special care on the part of the health authorities. This contributes to the permanent improvement of the people's health status.

The wide participation of society and of the population in the State activity for the protection, promotion and restoration the health of the population is a fundamental principle of Bulgarian public health. The activity of the population, directed and supported by the state organs, is a powerful stimulating factor for the successful fulfillment of all prophylactic and medico-social measures. The organizational forms of the participation of the population in Public Health are - the Standing Committees at the National Assembly; the district and municipal People's Councils; the health teams at the medical establishments; the members of the health groups organized in factories, schools and agricultural units, etc.

I. Hygiene and epidemiological activities

The hygiene and epidemiological care of the population is organized on different levels, in accordance with the administrative subdivisions of the country and the distributive principle of medical care.

Regional (local) level inspectorates are units and groups of hygiene and epidemiology - operating as branches of the "Inspectorates of Hygiene and Epidemiology". The groups of hygiene and epidemiology are organized in regions with up to 80 000 inhabitants. They are subordinated to the district inspectorates. One group consists of 2-3 physicians, several sanitary inspectors, laboratory technicians, disinfectors and others.

District inspectorates of hygiene and epidemiology are organized in the district towns with a population over 80 000 people. Teams of 18-20 physicians and other specialists with high and secondary medical education - chemists, biologists, sanitary inspectors, laboratory technicians and others are working at them. Some of the district inspectorates of hygiene and epidemiology are charged with national functions, too.

National (central) inspectorates of hygiene and epidemiology is functioning on national level.

The groups of hygiene and epidemiology and the branches of the inspectorates conduct a current sanitary control on public utilities, industrial enterprises, agricultural sites, public catering establishments and children educational institutions. They organize the fulfillment of the antiepidemic measures - immunizations, disinfection, disinsection and deratization.

The district inspectorates of hygiene and epidemiology execute specialized sanitary and epidemiological activities in the sphere of epidemiology, social hygiene, occupational hygiene, hygiene of nutrition, hygiene of children and adolescents, etc. The district services include microbiological, parasitological and chemical laboratories.

The national inspectorates of hygiene and epidemiology exercise a systematic guidance and control over all local medical services, renders practical assistance in the organization and execution of the state sanitary control, conducts a sanitary control over basic problems and over important sites with national significance, realizes the sanitary and technical expertises on standard projects, over sites of national importance, elaborate measures for prophylaxis and reduction of infectious and parasitic morbidity, carries out measures for the medical and sanitary protection of the country against quarantine and especially dangerous infections.

As a result of the close correlation of the services of hygiene and epidemiology and the network of medical services and the active cooperation of society and the population, considerable success was obtained in environmental sanitation on the basis of the respective sanitation programmes. Thus, for example, a number of industrial enterprises polluting the atmosphere were moved out of settlements. At present, 96 % of the population of the country uses pure drinking water from the central water supply system and 3.6 % from controlled local water sources. The number of industrial and agricultural sites reorganized in accordance with the hygienic standards, rules and requirements increase steadily. A great success has been attained in mining dust control and in the sharp reduction of pneumoconioses. The achievements in the limitation of the harmful effect of the chemical substances used in industry and agriculture are also considerable. A number of physiological and ergonomical problems are solved more and more successfully, as for example, the improvement of the regimens of work and rest, the introduction of new forking furniture, industrial equipment, etc. in accordance with the requirements of ergonomics.

Considerable achievements have been obtained in the endeavor for prevention, reduction and eradication of the infectious diseases in Bulgaria. This activity is conducted systematically and purposefully by the inspectorates of hygiene and epidemiology and by the medical establishments with the active participation of the administrative services and the social organizations. A basic role in that respect have the prophylactic immunizations, which, according to the Public Health Law are performed annually in accordance with an adopted immunization calendar. Their wide application permits the attainment of a great progress in the infectious disease control.

Table 1: Achievements in the struggle against the infectious and parasitic diseases in the PRB /morbidity per 100 000 people/

II. Health education

The principles, guiding planning, organization and management of health education activities in Bulgaria derive from the basic principles on which the public health system is organized. The significance of the health education in the public health system is stipulated by its prophylactic tendencies and by the active and mass participation of the population in the versatile activities for the health protection of the people. The health education is a State responsibility realized by its organs and is under its direct management.

Health education activities in the country are directed towards the formation of such health behavior and education, which, will enable every citizen to protect and promote his own health as well as the health of his family and his relatives. On the second place, the health culture stimulates the initiative of the population and of the individual person to participate in the realization of sanitary measures and measures for environmental sanitation, transforming each citizen into an active champion of the people's health and welfare.

In order to realize these activities, specialized services for health education were formed in the framework of the public health system. An "Institute for Health Education" has been created at the Ministry of Public Health, aiming at the organization and scientific guidance of health education in the country. Irrespective of that, department of Health Education were organized in all district inspectorates of hygiene and epidemiology. Their duties were twofold - to carry out health education by their own means and to organize the involvement of all health establishments and medical workers in health educational activities. At the same time, the Institute is responsible for the publication of different materials indispensable for the regular and purposeful direction of health education activities, such as: theses for lectures and meetings, films, slides, placards, exhibitions, leaflets, booklets, etc. Series of health lectures are issued, too - "Library of Health", "Health Lectures for the Worker", "Health Lectures for the Rural Population", Health Lectures for the Pupil", "Nutrition and Health", etc.

The health education in the country is conducted not only by the organs of the public health system, but, also by a number of other state institutions and organizations - the Ministry of Education, the Committee of Culture, the Bulgarian Cinematography, the Trade Unions, the Youth Organization, the Committee of Bulgarian Women, the Committee of Soberness and others. The activity of all these institutions is coordinated and directed systematically by the Ministry of Public Health and the National Council for Health Education, created on social principles at the same Ministry.

The Bulgarian Red Cross also displays widescope activities in the field of health education. Annually, thousands Bulgarian people are trained in different courses organized by this mass organization. In only one year, more than 300 000 people attend the courses on nutrition, on nursing ill people at home, on longevity, on the hygiene of youth, on hygiene of marriage, on hygiene of living conditions and others. Thousands of health posts render first aid and take care of the hygiene and the dissemination of health education on social principles. Especially significant is the activity of the Bulgarian Red Cross in the schools. There, this activity is directed towards the hygiene education of the pupils, including their participation in the struggle against smoking and drinking, their sexual education and their training in the health posts for rendering first aid, etc.

A considerable part of the work for the promotion of population health culture is carried out by the Fatherland Front - the largest social and political mass organization in the country. Through this organization thousands of health lectures and various prophylactic measures are organized annually in towns and villages.

III. Organization of primary medical care

Out-patient and day-patient care is the most mass type of medical care. In the outpatient departments, to a large extent, the problems of prophylactics, diagnostics, treatment, occupation-medical expertise and rehabilitation of the majority of the people in need of medical care are solved. This determines the leading role of the outpatient departments in the solving of the problems connected with the health status of the population.

The microregional principle (territorial and occupational) is accepted as a basic principle of primary medical care in the contemporary organization of outpatient care. The microregional system for outpatient medical care reflects in its contents the synthesis of the prophylactic and curative medicine. In Bulgaria the following physician's and dentist's microregions are organized, in accordance with the size and the territory dislocation of the attended contingent:

The village health microregion is organized in one or several villages with a population of 1500 - 3500 people. In such microregions qualified primary medical care is provided to the entire population. Every microregion is attended by a team formed out by a physician, a dentist, a midwife, nurses, physicians's assistants and auxiliary medical personnel. Dispensaries headed by physician's assistants (sometime called feldshers) are organized in order to ensure health care in small constituent villages in the structure of the village health microregions. In them, the physician's assistants work under the guidance of the microregional physician.

The therapeutic microregion organized in the towns and cities is the basic unit in the infrastructure of the outpatient medical care of adults. It covers a territory with adult population of 3000 - 3500 people. A team of physician-general practitioner or specialist in internal medicine, nurses and physician's assistants work there. For the medical care of the nearby villages, the therapeutic microregion includes in its structure physician's assistant's dispensaries in order to provide health care to the inhabitants of the nearby villages.

The enterprise-departmental physician's microregion is organized in enterprises for ensuring medical care for 1200 - 2000 workers. The medical team of the departmental microregion is composed of a physician (G.P.), a dentist, a physician's assistant and a nurse. In enterprises with more than 800 women workers - a midwife is included in the team. Physician's assistants dispensaries are organized in distant departments of the enterprise with more than 200 workers.

The pediatric microregion is organized for the attendance of 1000 children, on an average, aged up to 15. A microregional pediatrician and two nurses - a microregional nurse and a patronage nurse - are included in its structure.

The school health microregion is organized for 200 and more pupils. The necessary pediatric or internal medical care is ensured in accordance with the age of the pupils. There a school physician - pediatrician or internal medicine specialist - is working aiming at the specific medical problems of the rising generation. Nurses and physician's assistants are included in the team.

The obstetric and gynecological microregion is organized on a territory with a total population of 17 000 - 18 000 people or in industrial enterprises with more than 4000 women workers. A primary, specialized obstetric and gynecological care is provided. The team of midwives is headed by an obstetrician-gynecologist. In the rural medical service, in which an obstetric and gynecological microregion is not organized, a maternity health center is organized and managed by the medical worker in charge of the dispensary. He ensures the prophylactic surveillance only on women with normal pregnancy, while, these with pathologic pregnancy are looked after in the outpatient department of the regional or district hospital.

The stomatological microregion forms an integral part of outpatient medical care and is a constituent part of the dispensary, or of the outpatient department's stomatological ward of the regional (local) hospital, or of the district stomatological outpatient department. It attends on a territorial principle the population elder than 18 years, while, the children and the pupils are attended by profiled children's and school's dentists. In the industrial enterprises a departmental stomatological microregion is organized.

The types of the health microregions described above, provided the majority of the people with primary medical care in internal medicine, pediatric, obstetric - gynecological and stomatological aspects. Primary medical care in the remaining aspects is provided by the general outpatient departments, in the specialized outpatient departments and in the district stomatological outpatient departments. A successful supplement to the microregional principle in the country is the widespread organizational form of team care /see Fig. 1/. The basic sense and contents of this form is expressed in the following: the microregional principle becomes essential not only for the internal medicine specialists, pediatricians and obstetrician-gynecologists but also for the other specialists in the outpatient departments. In compliance with the capacity of the establishment - one, two or more teams are organized composed of 5-6 microregional internal disease specialists, pediatricians, obstetric-gynecologists, a surgeon, a neurologist, an eye-specialist, an otorhinolaryngologist and a dermatologist. All these attend patients in a synchronized schedule. That creates a possibility for timeliness, quality and complexity of the diagnostic and curative process.

IV. Structure of the primary medical establishments

The widespread network of outpatient establishments and dispensaries in this country provides the population with free of charge, accessible paramedical help and qualified, specialized medical care. The medical services of general type, that, provide the population with primary medical care classified according to their capacities are the following:

The outpatient departments are complex medical establishments, delivering qualified and specialized primary consultative outpatient medical care - both, to the urban and to the rural population. They are developed as part of the regional, district or labour hospitals and as an independent establishments. The number of the outpatient departments in the towns is in accordance with the number of the inhabitants, and, their dislocation is in conformity with their necessary closeness to the attended population. An outpatient department in the big cities attends about 40 000 people on an average.

The outpatient departments, according to the number of the attended people and the functions they execute, are divided in five types. In them, an assistance of determined specialty is provided in conformity with the type of the outpatient department. The outpatient departments of type I, II and III are organized in the towns and cities. These of types IV and V are organized chiefly in the larger central villages. In the latter, according to prearranged schedules, different specialists are working - surgeons, neurologists, otorhinolaryngologists, ophthalmologists and others coming from the regional or district hospitals with a view to bringing the specialized primary medical care closer to the rural population.

The labour outpatient departments are organized at the industrial sites and complexes with more than 10 000 workers. As a rule, they are included in the structure of the regional or the workers hospitals.

The stations for urgent medical care exist as an independent health establishments only in the largest cities. They provide urgent medical care of the basic and some other specialties, such as: internal medicine, surgery, obstetrics-gynecology, cardiology, reanimation, traumatology, neurology, toxicology and others. The specialists according to their specialty are included in the staff of specialized teams, who, dispose of adequately equipped means of sanitary transportation.

The departments for urgent and emergency care are structurally incorporated into the outpatient departments of the district hospitals. Teams of medical workers with higher college and secondary medical education who are specialists chiefly in internal medicine and pediatrics, together, with specialized teams in conformity with the needs of the population - are working in them. The services for urgent and emergency medical care at the regional hospitals have the same functions but their staff is smaller.

All the stations, services and departments for urgent and emergency medical care use in their routine practice appropriate medical technology for the conduction of life-saving measures on the place of accident and during the transportation of the patient to the health establishment, as well as, modern means of communication: radio-telephone, distant recorder of electrocardiogrammes and others. In the structure of the National Station for Urgent Medical Care in the capital of Bulgaria - Sofia, the service of urgent consultations and medical aviation, disposing of modern transportation means including medical airplanes and helicopters, is included. At the day and night's disposal of this service are 250 habilitated specialists from the Medical Academy.

The dispensaries or so-called "outpatient and inpatient departments", provide primary specialized and consultative medical care on some problem disease in the public health network. Such are pneumophthisiologic, oncologic, psychiatric and dermovenerologic dispensaries. They provide specialized medical care to one or several districts, work in close interaction with health establishments of the general type and guide them systematically according to their specialized work.

Parallel with the insurance of primary medical care by the microregional physicians and by the outpatient departments specialists, the citizens have the possibility to choose - in accordance with their desire and preferences - a free of charge medical care from a highly qualified specialist, such as: head of hospital ward, head of clinic, habilitated specialist, etc. For this purpose scheduled hours for consultations of the patients in the outpatient departments are fixed. In the PRB exists a specially created organizational system, which, permits every person for whom the physician in charge on a given level decides that he needs more qualified and specialized medical care - to be sent to an establishment of a higher level. The system stipulates a special documental exchange of information between the different levels including feed-back of information.

In the activities of the general and specialized outpatient establishments network (the activities of the microregional physician and the different specialists working in those establishments) a basic method is the follow-up. These activities involve:

- planning, organization and carrying out of different kinds of prophylactic examinations of certain age, sex and occupational groups of the population with a view to the early discovery of the risk factors - occupational, communal, hospital - and the diagnostics of the early forms of some diseases which at that stage have the characteristics of mass and problem diseases for the country;

- the exact diagnostics of each individual case, clarification of the health condition of definite priority groups of the population (children, pupils, pregnant women, heavy load workers, etc), prescription of the necessary prophylactic curative and rehabilitative measures, planning and organization of dynamic surveillance of the followed-up patients and of the group of people at risk;

- realization of the planned measures in respect of the protection and sanitation of labour and living environment of man, increasing and strengthening the protective forces and supporting the adaptive mechanisms of the organism, promotion of health knowledge and formation of healthy habits among the population, systematic and active control of the results of the conducted health measures, introduction of eventually imposed corrections of the primary programmes, etc.

More on follow-up method in Bulgaria can be found in the monograph from WHO, namely: "D. K. Sokolov, J. E. Asvall, H. Zollner. The Gabrovo Health Services Model in the People's Republic of Bulgaria. Copenhagen: World Health Organization - Regional Office for Europe /EURO Reports and Studies 27/, 1980."

V. Organization of specialized medical care

The hospital network in Bulgaria is organized as a stage system comprising four levels - regional (local), district and national.

On a regional level, hospital care is provided in the united regional hospital. Its capacity is about 300 - 600 hospital beds. There are wards for internal diseases, pediatrics, surgery, obstetrics-gynecology which are organized obligatory, as well as, some specialized wards such as ophthalmological, otorhinolaryngological, neurological and others.

On a district level the district hospitals with 600 to 1200 hospital beds are organized for satisfying the needs of the population of the corresponding administrative unit (200 000 to 400 000 inhabitants). These are wards according to a broader nomenclature and include cardiologic, endocrynilogic, urologic, orthopedic, traumatologic and other wards.

On a national level specialized centres of pulmo- and cardio- surgery, organ's transplantation, keratoplastics and others are organized.

At the end of 1976, in 184 hospitals of the country 67 220 beds were functioning, which shows that the bed-population ratio was 85 beds per 10 000 people and that the admission rate was 16.4 per cent.

The sanatorium-resort care in Bulgaria disposes of precious resorts. More than 500 mineral sources were discovered with different composition and temperature of the water. Besides, there are firths and peats-bogs sources of curative mud and resorts with favorable climatic conditions. Some of the mineral sources, as these in Hissar, Kyustendil, Sofia and others were discovered and have been used as curative centres as far back as the time of the Roman Empire.

Sanatorium-resort care is considered as a stage in the carrying out of outpatient and hospital care. This type of medical care provides the realization of part of the planned in other medical establishments physioprophylactic, physiotherapeutic and medical rehabilitative measures. A harmonious system of continuity between the sanatorium resorts and the other medical establishments is organized, ensuring the sequence in the realization of the planned medical measures.

In 1976, the sanatorium bed-population ratio was 21 beds per 10 000 people. Considerable part of these beds were determined for the treatment of children and adults.

The medico-social assistance in Bulgaria comprise 15 209 berths in 158 establishments for social assistance - boarding houses for old people, boarding houses for honored revolutionists, homes for disabled people, homes for children and adults with physical impairment or mental disorders, hostels for students in the training and industrial enterprises, etc. In 49 settlements of the country the so-called "Social Home Patronage" is organized, by which different types of services (food delivery, cleaning of the lodgings and other services) are ensured for old and incapable for self-attendance persons. In order to make life of old people worthwhile, 356 "Clubs of the Pensioner" have been organized in Bulgaria.

VI. Medical science and training of medical staff

Medical science is of special importance for public health in the broad sense of the term, including primary medical care - because - it ensures the outlining, the planning and the conduction of scientifically grounded measures. The scientific investigations about the health of the population and the conditions and the factors that determine it, about the needs of the population in medical care, about the requirements to create an effective health organization, about the clinical diagnostic curative and rehabilitative problems, etc. are of such nature that they can introduce essential changes in the approach to the protection and restoration and promotion of the health of the people. A basic element of science and of the realization of a comprehensive medical care is the medical staff.

All scientific and higher educational institutes in the country are integrated in an uniform scientific and educational complex - the Medical Academy - composed of 24 scientific institutes, 3 medical, 2 stomatological and 1 pharmaceutical Faculties. In this complex, the training of the students in medicine, the post-graduate education of the medical staff and the scientific activities are concentrated.

The paramedical staff is trained in institutes dislocated on the territory of the country. Their training takes 2-3 years depending on the specialty. At present, 19 institutes are functioning in Bulgaria, in which physician's assistants, midwives, nurses, laboratory technicians, X-ray technicians, rehabilitators, assistant pharmaceutists, nutrition inspectors, dental technicians and others are trained.