Bulgaria

Bulgaria is experiencing negative population growth since the early 1990s due to high emigration. As from 1989 to 2012 the population dropped from 9.0 million to 7.3 million i.e. by almost 20%, it also became considerable older as it was primarily the younger who left and the fertility rate dropped to below 1.5.

In the period 2020-2060, the share of people aged 80+ in the Bulgarian population is expected to almost double.[1] Over the same period, the old age dependency ratio defined as the ratio of the number of elderly people at an age when they are generally economically inactive (aged 65 years and over) compared with the number of people of working-age (15-64 years), will rise from 34.3% to 56.1%[2] (EU-27: 32% to 54%[3]).

The average life expectancy of Bulgarians is slightly rising, but remains the lowest in the EU – 74.8 years for the period 2015-2017. Life expectancy for men and women at age 65 is projected to rise from 14.2/18 years (EU-27: 18.1/21.6) in 2018 to 20.6/23.6 years (EU-27: 22.4/25.6) in 2060. In 2018, the healthy life expectancy at 65for men and women was 9.2 and 10.2 years respectively.

Under an assumption of no policy change the Ageing Report scenario suggests that public expenditure as a share of GDP would rise from 0.4% to 0.6% (EU-27: 1.6%-3.1%) by 2070. The impact of a progressive shift from the informal to the formal sector of care in Bulgaria would entail an estimated increase by 125% in the share of GDP devoted to public expenditure on long-term care (128% on average for the EU27).

[1] National Statistical Institute, see at https://www.nsi.bg/en/content/2994/population-projections-sex-and-age

[2] National Statistical Institute, see at https://www.nsi.bg/en/content/3000/projected-old-age-dependency-ratio-districts-and-sex-until-2080

[3]Eurostat, see at: https://appsso.eurostat.ec.europa.eu/nui/show.do?query=BOOKMARK_DS-877994_QID_-3385F7B5_UID_-3F171EB0&layout=TIME,C,X,0;GEO,L,Y,0;PROJECTION,L,Z,0;INDIC_DE,L,Z,1;INDICATORS,C,Z,2;&zSelection=DS-877994INDIC_DE,OLDDEP1;DS-877994INDICATORS,OBS_FLAG;DS-877994PROJECTION,BSL;&rankName1=INDICATORS_1_2_-1_2&rankName2=PROJECTION_1_2_-1_2&rankName3=INDIC-DE_1_2_-1_2&rankName4=TIME_1_0_0_0&rankName5=GEO_1_2_0_1&sortC=ASC_-1_FIRST&rStp=&cStp=&rDCh=&cDCh=&rDM=true&cDM=true&footnes=false&empty=false&wai=false&time_mode=NONE&time_most_recent=false&lang=EN&cfo=%23%23%23%2C%23%23%23.%23%23%23

To date, there is no definition of long-term care (LTC) in the Bulgarian legislation, nor any official classification of who qualifies for it. The most recent strategic documents use the definition given at EU level. As in many other countries, the social and health care sectors in Bulgaria are regulated by different legislation and fall within the remit of different bodies. Social services are regulated by the Social Services Act (SSA) and are decentralised and managed by the mayors of the respective municipalities. Municipalities are responsible for the provision of social services that are financed by the state budget or the municipal budget. Health services, on the other hand, are regulated by the Medical Treatment Facilities Act and are provided through different types of institutions such as hospitals for further and continuing treatment, hospitals for rehabilitation and hospices.

A comprehensive reform of the social services sector was launched in the past years, starting with the adoption of a National Long-term Care Strategy in 2014.[1] The Strategy aims to improve over the next 20 years access to social services in the community and family environment, as well as to health services. It will do this by improving the diversity, quality, integration, volume and scope of these services. Deinstitutionalisation is presented in the Strategy as a main target for long-term care reform. Patronage care, which already exists, will be further developed and expanded with a view to improving the quality of life and opportunities for social inclusion for older people and people with disabilities.

In July 2019 a new Social Services Act[2] came into force with the objective to modernise the regulatory framework in social services and to improve their planning, accessibility, management, financing, quality, effectiveness and monitoring. The Law establishes a new Agency for the Quality of Social Services at the Ministry of Labour and Social Policy. There are two very important deadlines in the Transitional and Final Provisions of the Act: the final closure of all medical and social care homes for children (by 2021) and of all homes for adults with disabilities (by 2035). In November 2020 detailed Rules for the Implementation of the Social Services Act entered into force. The social services’ reform, including long-term care, is also supported by the implementation of the ‘New Standards for Social Services’ project which was introduced in 2016 and which resulted in June 2022 in a long and very specific Ordinance on the Quality of Social Services.[3]

Public spending on the health and social services sectors is also increasing. Thus, in 2020 there was an increase by BGN 30 million (approximately EUR 15 million) in the funds for social services and the total amount was over BGN 290 million. In order to improve access to health services, an increase of 9.5 % was set in 2020 compared to 2019. The funds were aimed at increasing the volume and scope of clinical pathways and activities related to the prevention and prophylaxis of socially significant diseases, which are the most common cause of death or permanent incapacity for work and injuries.

The geographical coverage of long-term social care and other social services is uneven compared to long-term health care services which are more accessible across the country. It should nevertheless be noted that, in recent years, there has been less growth in health services than in social services. While the number of available beds in hospices has grown steadily in the last decade (and almost tripled in seven years), the number of establishments and personnel as well as the patient-to-personnel ratio remained almost unchanged, which raises important questions regarding the quality of services.

More than 90% of services are public, provided by either the state or the municipality. While institutional care is almost entirely public, non-governmental organisations (NGOs) and charities are increasingly involved in the provision of services in non-institutional centres for social rehabilitation and day care centres for adults. Home-based services are provided by individuals contracted by the municipalities or the state, depending on the type of service.

Regarding accessibility of the social services, the new SSA gives priority to support in the home environment and in the community. The use of social services for residential care is allowed only if the possibilities for supporting people through social services at home and in the community have been exhausted. Anyone who needs support for the prevention and/or to overcome social exclusion, exercising rights or improving their quality of life, regardless of age, health condition, education, income, social and property status, is entitled to social services. Social services are provided upon the request of the potential beneficiary and after a preliminary assessment of the need for social services and the establishment of an individual needs assessment and an individual support plan. Everyone has the right to use the generally available social services without a preliminary needs assessment. Social services can be used: short-term – for a period of up to six months; medium-term – for a period of up to one year; long-term – for a period of between one and three years. As the SSA came into force on 1 July 2020, no data is available yet on how the objectives and ambitions of the law as described above translate into practice.

[1] https://www.strategy.bg/StrategicDocuments/View.aspx?lang=bg-BG&Id=882

[2] https://www.lex.bg/bg/laws/ldoc/2137191914

[3] https://www.lex.bg/bg/mobile/ldoc/2137223813

Number of carers

In 2016, the number of LTC workers providing informal care was 1 per 100 individuals aged 65 and over, 87.7 % of whom were women. The share of the population providing informal care was 6.1 %, among which the share of informal carers providing more than 20 hours of care per week was 36.6 %.

The population will continue to grow older due to low birth rates, emigration of younger generations and increased life expectancy. While the prevalence of informal care has grown over the 21^st century, the decreasing number of younger and healthier family members may reduce the availability of informal carers. Deinstitutionalisation may nevertheless put additional pressure on family and informal carers, and worsen their work-life balance.

Recognition and definition of carers

In Bulgaria there is no established information system collecting data on formal carers providing long-term care. There is even less information about the number of people providing informal care. But there is little doubt that the overwhelming bulk of LTC is provided by informal carers in families.

The cultural traditions in Bulgaria encourage care for elderly people to be provided by family members, who are not trained professionally, but accept that responsibility out of a sense of family duty. The provision of LTC is considered to be a family matter.

It remains to be seen whether the ambitious sectoral reform measures and the newly introduced legislation, which aims to modernise the social services will make a difference in the future.

Identification of carers and assessment of their needs

Since January 2019, the Personal Assistance Act, which regulates the Personal Assistance Mechanism, has been in force. The provision of personal assistance began in September 2019. According to the Act, the assistants selected by the user, may be family members of the disabled person, part of the extended family circle, or those outside. After an interview and approval by the municipality, the assistant must be added to the list of assistants maintained by them. The user of the personal assistance participates in the negotiation, management and control of the type and duration of the work performed by the assistant. Although the purpose of the mechanism is to support people with disabilities, it can also support family members. Informal carers can receive support in accordance with the new Social Services act. The SSA introduced entirely free support and training services for family members who provide informal care at home for people with permanent disabilities and for people with disabilities over the working age who are unable to look after themselves. In this way, the state provides an additional opportunity to support those who care for their older relatives. As mentioned, it is too early to assess the effectiveness of these provisions.

Multisectoral care partnerships

The new Social Services Act (in force since July 2019) envisages and defines an integrated approach in providing social services. According to Article 129 of the law the integrated approach may include coordination and interaction with other systems; coordination and interaction within the social services system and the provision of integrated intersectoral services. There is no information on the application in practice of this provision.

Access to information and advice

Under the new Social Services Act (in force since July 2019) informal carers can receive support. The new law introduced entirely free support and training services for family members who provide informal care at home for people with permanent disabilities and for people with disabilities over the working age who are unable to look after themselves. The implementation of the new provisions is still to be assessed.

Access to respite care

The new Personal Assistance Act which is in force since January 2019 regulates the Personal Assistance Mechanism. The provision of personal assistance began in September 2019. According to the Act, the assistants selected by the user, may be family members of the disabled person, part of the extended family circle, or those outside. After an interview and approval by the municipality, the assistant is added to the list of assistants maintained by them. The law also establishes the right to respite care for families and people caring for adults with permanent disabilities and for older people in need of care at home. The Regulation for application of the law, which is in force since November 2020 lays down the procedure for requesting and using respite care. There is no information yet on how the new procedure works.

Training and recognition of carers’ skills

Since January 2019, the Personal Assistance Act assistants (which can be family members of the disabled person, part of the extended family circle, or those outside) can receive training by the municipalities but it is not mandatory.

Social inclusion of carers, access to education and employment

Carer’s leave

The law provides an opportunity for people to take leave from work to take care of a sick family member. Every insured person is indeed entitled to 10 days of paid leave per calendar year to provide care to sick family members over the age of 18, or to accompany them for medical examination, investigation or treatment either in the country or abroad. Those who provide the same care for family members under the age of 18 are entitled to up to 60 days in one calendar year.

In addition, people may use unpaid leave for the same purpose, but this is subject to employer approval. Periods of up to 30 days of unpaid leave per year do not affect entitlement to old age pension.

Interestingly, official regulations set different terms and conditions in relation to granting sick leave for the care of an ill family member at home compared with hospital inpatient care. A medical sickness certificate regarding care for a sick family member in hospital is issued by the doctor after the head of the hospital has agreed that care for the patient is necessary for a specified period. The certificate is granted provided that, at the place where the patient resides, there is no other unemployed family member able to care for or accompany the patient. This is established through a declaration by the insured person to whom the certificate is issued.

A medical sickness certificate allows for the care of an ill family member at home, and care of a child placed with relatives or foster family, under Art. 26 of the Law on Child Protection (LOC). The medical sickness certificate can be issued by:

• A doctor (or a dentist) – 14 days continuously for one or more diseases.
• A Medical Advisory Committee – up to 30 days at a time, but not more than 6 months.
• A Territorial Expert Medical Commission – after 180 uninterrupted days, or 12 months with a break, in the two previous years of illness.

For care of a chronically ill family member, a medical sickness certificate is issued and monetary compensation is paid only when: a new disease is added that aggravates the condition and needs care; there is an exacerbation of the existing disease; or the disease reaches a terminal stage.

Cash Benefits

Financial support to informal carers was available until the end of 2019 through a dedicated programme – National Programme ‘Assistants to people with disabilities’. The provision of personal assistance began in September 2019, following the entry into force of the new Personal Assistance Act, which regulates the Personal Assistance. According to this act, the assistants is selected by the user and may be a family member, part of the extended family circle, or those outside. Once selected as an assistant the informal carers can receive support in accordance with the new Social Services act. The procedure and its results are yet to be evaluated and no information is currently available regarding its effectiveness.

Monthly benefits for the care of a disabled child are payable regardless of family income until the age of 18 and until the completion of secondary education, but no later than the age of 20 of the child. Each year, the Ministry of Labour and Social Policy determines the amount of aid for raising a child with disabilities. In 2021 the monthly benefits for raising a child with 90 and over 90 per cent disability was 930 BGN per month (i.e. about €485), with 70 to 90 per cent disability was 450 BGN per month (i.e. about €230) and with 50 to 70 per cent disability was 350 BGN per month (i.e. about €178).

• The 2021 Long-Term Care Report, Trends, challenges and opportunities in an ageing society, EC 2021
• The 2018 Ageing Report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2018
• ESPN Thematic Report on Challenges in Long-Term Care, Bulgaria, EC, 2018
• ESPN Thematic Report on work–life balance measures for persons of working age with dependent relatives, Bulgaria, 2016
• Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability, EC, 2016
• Adequate social protection for long-term care needs in an ageing society, European Commission, 2014