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 2013-2060, the share of people aged 80+ in the Bulgarian population is expected to almost triple, i.e. grow from 4.3% to 12.1% (EU-28: 5.1%-11.8%). Over the same period, the share of people 85+ will expand by more than a factor 3 from 1.6% to 6.3% (EU-28: 2.3%-7.0%) and the old age dependency ratio measured as the percentage of 65+ compared to the 20-64 year old population will rise from 30.6% to 64.8% (EU-28: 29.9% to 55.3%).
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).
Bulgaria’s long-term care (LTC) system is largely underdeveloped and services are delivered by a variety of care institutions and programmes, regulated by various laws. These do not operate under a rationalised, well-organized and institutionalised body. The services provided by these institutions are of limited coverage and quality, and are inadequate to meet the growing needs of the population. This places a significant financial and practical responsibility on the family.
To date, there is no definition of long-term care (LTC) in the Bulgarian legislation, nor any official classification of who qualifies for it. As in many other countries, the social and health care sectors do not have any official mechanism for coordination with regard to the delivery of long-term care services. A National Long-term Care Strategy, adopted by the Council of Ministers in 2014, nevertheless aims to improve access to social services in the community and family environment, as well as to health services, over the next 20 years. 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. As it stands though, health and social services are regulated by different bodies and legislation. In addition, LTC may be provided by the state, the municipal authorities or private providers via social insurance and social welfare depending on the specific case.
In Bulgaria, Long-term care and other social services for the elderly are offered through two distinct systems. Social services, defined as ‘activities which support and expand a person’s opportunities to lead an independent life and which are carried out at specialised institutions and in the community’ are regulated by the Social Assistance Act (SAA) and Rules for the Implementation of the Social Assistance Act (RISAA). Social services provided for a period of more than 3 months are considered long-term social care. Social services in the community are provided through personal assistants, social assistants, home assistants, home care, day care centres for children and/or adults with disabilities, day centres for elderly people, and centres for social rehabilitation and integration.
Health services, on the other hand, are regulated by the Medical Treatment Facilities Act and LTC services are provided by the healthcare system in different kinds of specialised medical institutions, such as: hospitals for long-term and continuous treatment, rehabilitation hospitals, state psychiatric hospitals, centres for mental health and hospices, which are a key institution for the provision of long-term care in the country.
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.
To access social services, beneficiaries must submit a written request to the appropriate municipal or national authority for public services, or to the manager of a private service provider. Based on the request, the relevant authorities conduct a social evaluation and make a recommendation for placement of the beneficiary. Services are provided if certain criteria and conditions are met; these depend on the type of service, disability, income, whether there are family members who can care for the person, etc. Once placed in a residential institution, care recipients must pay a fee for their stay, which – in most cases – amounts to 70% of their monthly income and should not exceed the actual monthly cost of the service provided. The fee for community-based social services, including residential-type services, is significantly lower. Persons with no income or bank savings do not pay a fee. Access to health services is based on the insurance status of the beneficiary. However, every Bulgarian woman over the age of 60 and every Bulgarian man over 65 has full health insurance coverage paid by the state.
 State Gazette No. 120/2002 of Social Assistance Act 1998.
Number of carers
Although no precise data is available for Bulgaria, given the lack of a formal definition, the prevalence of informal care in the country has been estimated at 10% of the total population (about 700.000 people).
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 21st 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.
 European Quality of Life Survey, Eurofound, 2016
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.
Though informal care thus is of outmost importance it has so far neither been legally recognised or financially encouraged within the system of LTC services. No cash benefits or services in kind are available to support informal carers. And in line with this one of the placement requirements of LTC institutions for the elderly is that the clients do not have any family members capable of providing care for them.
Social inclusion of carers, access to education and employment
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.
In Bulgaria, there is no remuneration system for informal services provided by family members. Monthly-based financial social assistance can be claimed by someone caring for a seriously ill family member. People are entitled to a monthly allowance if they either live alone or are in a family whose income for the previous month is lower than the differentiated minimum income. This applies to carers acting as either personal assistants (relatives) or social assistants (professional employees). The right to disability pension is awarded when the person has at least 50% reduced working capacity. Pensioners with a degree of disability over 90%, who need constant help, receive an additional pension allowance of 75% of the social pension for old age.
Monthly benefits for the care of a disabled child are payable regardless of family income. Each year, the Ministry of Labour and Social Policy determines the amount of aid for raising a child with disabilities. In 2014, the monthly allowance for a child up to the age of two was 100 BGN per month (i.e. about €51); the monthly assistance for a student with a disability, up to the age of 20 years old, was 70 BGN per month (i.e. about €36).
State-supported community-based services for carers, such as respite support, training, and counselling are very limited. Some respite support for carers is obtainable from private service providers, if the family can afford it financially.
Due to lack of funds there has been a temporary suspension of the remuneration system that applied to carers acting as personal assistants (relatives) and social assistants (professional employees), providing care to lonely old people and the disabled (people with over 71% proven permanent disability). Social assistants who provide support with cleaning, personal hygiene, shopping and other everyday tasks are now provided by private companies at different prices depending on the region, combination of services etc.
- 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