Access to healthcare for refugees from Ukraine in Bulgaria
On 25.01.2023 a webinar was held with practical health advice for Ukrainian citizens. On 28.01.2023, a face-to-face meeting on the same topic with Ukrainian citizens took place. The moderator of the webinar and the seminar was by Dr. Miroslav Spasov, a general practitioner from Sofia.
Dr. Spasov began the session with a presentation on the health insurance system of the Republic of Bulgaria. All presentations were simultaneously interpreted for the Ukrainian citizens.
In Bulgaria, the health care system is of “mixed” type. This means that the basic package of medical services to which insured citizens are entitled is provided by the NHIF (National Health Insurance Fund). Additional medical services are paid to the respective health insurance funds, each of which corresponds to a different financial package. Of course, a private paid medical examination can always be paid for if the medical service and activity is not covered by the mentioned health packages.
In case of 3 months of non-payment of health insurance, the medical rights are discontinued and medical examinations and tests as well as other medical services must be paid for at market prices.
WHAT RIGHTS DO YOU HAVE AS HEALTH INSURED PERSONS?
In fact, a lot of rights are covered. 1. Affordable and quality health care; 2. Information about my health condition and treatment methods; 3. Primary, specialized outpatient medical care; 4. Medical diagnostic tests; 5. Highly specialized medical activities; 6. Dental care; 7. Hospital care; 8. Home medication;
You are entitled to all of these as a health insured person. And here it is also important to mention the health insurance booklet, which you can get from the regional health insurance funds in the country – National Health Insurance Fund (NHIF) (nhif.bg) This is the document which you need to exercise all of the above rights.
The health insurance booklet has a section where the family doctor and family dentist can be specified (in case there is a change, to which you are entitled).
We are all free to choose our personal physician, also known as a personal physician, family doctor, general practitioner or GP. We approach this medical professional if:
- We have a health problem and need advice;
- We need to have a medical examination;
- We need home or hospital treatment;
- Our medical condition requires the prescription of medication.
When prescribing medicines there are three types of medication prescription forms that the GP can use. The green form is used when prescribing sedatives; the yellow form is used for serious diseases and the most common form, the white form, is used to prescribe medicines for chronic or acute illnesses such as colds, inflammations etc.
The fixed fee payable to the GP for an examination is BGN 2.90. There is no charge for examination of children. Medical workers and various organisations are demanding that this should fee be raised to BGN 8 and that a fee should be charged for the examination of children, but so far no action has been taken in this regard. This demand comes because of the rising inflation and the former practice of linking the fee to the minimum wage (1% of the minimum wage), following the vote in Parliament to increase the fee only recently.
It is important to note that persons with refugee status do not pay this fee, but if certain types of medical documents should be issued, such as: medical certificate when applying for a job, for the issue of a driving licence, medical notes for absence from school, etc. – a corresponding charge is paid.
Below is a chart of all the possible health insurance coverages a health insured person is entitled to and the way they can be obtained.
We have already outlined the rights and now we should discuss the responsibilities. In order to have health insurance we need to do the following:
Pay our health insurance regularly;
- We must present our personal health insurance booklet whenever we visit our GP or dentist;
- We need to visit our GP for compulsory check-ups, examinations or immunisations;
- We must comply with doctor’s prescriptions and disease prevention requirements;
- The internal rules of the medical or dental care facility where medical or dental care is received must be observed;
- The professional and human dignity of health professionals must be respected;
- One must not intentionally harm one’s own health or the health of others;
Persons under the age of 18 are insured by the state and receive health care free of charge from a chosen personal physician. This also applies to persons with refugee status. It is important to choose a GP for your child.
Health insurance for parents is a bit more complicated, but there are a number of options and alternatives. For the first 3 months of stay in Bulgaria, the health insurance contributions of refugees are covered by the Bulgarian state, but after that they have to pay these themselves.
They have the following options: Option 1 – Signing an employment contract in Bulgaria and having the employer pay the health insurance contributions. In this case refugees are able to choose their GP in the preferred location.
Option 2 – Refugees pay their monthly health insurance contributions to the National Revenue Agency (NRA) in their regional town of residence. The monthly health insurance contribution is BGN 28.40.
If you are unable to take up a job or pay your own health insurance, you can still get medical help in an emergency. In Bulgaria, emergency medical care is free for all people of all ages. It can be obtained by dialling 112 or in emergency departments in some hospitals.
To use the services of a GP your health insurance rights must not be suspended. They can be paid on a monthly basis or in advance for up to 1 year. Dr. Miroslav Spasov recommends paying health insurance one month in advance due to system problems and numerous hacker attacks, after which information is lost and not updated on time.
In addition to emergency care, in case of out-of-hours of your GP, you can also turn to the emergency care unit, with which every GP has a contract.
As an insured person, you should know that the National Health Insurance Fund (NHIF) guarantees a minimum package of medical activities. Although this is a minimum package, in Bulgaria it includes quite a wide range of services. Yet not all healthcare services are fully paid for by the NHIF (for example, thyroid ultrasound).
If you have a health problem, seek medical help from your GP by making an appointment for a check-up (according to his/her working hours). The examination is carried out in the GP’s office, which is certified by signing the medical records.
It should be noted that the majority of personal physicians are over 50 and have studied Russian, whereas those aged under 40 speak English, so they would be able to communicate with Ukrainian citizens.
Referrals or medico-diagnostic tests are issued by the GP after examination. Referrals are not issued without an examination. At the discretion of the medical practitioner, examinations and/or consultations with a specialist are assigned. For this purpose e-referrals are issued. If necessary, the GP may also refer the patient for hospital treatment. There is no limit to the number of referrals that can be issued by a GP in one visit.
There are medical referrals that are not covered by the NHIF, which means they have to be paid for. Different laboratories have different pricing policies and ways of working in relation to patient service, sample collection, processing time, time and method of obtaining the result. For some tests, different laboratories use different methods and apply different reference values. It is important to note that test results are not a diagnosis and a physician should be consulted.
After you are examined and have a consultation with the relevant specialist you should inform your GP of the opinion of that specialist. This is done to keep your GP informed and if necessary to seek new treatment options or have medical referrals issued.
In order for children of persons with refugee status to be admitted to nurseries, kindergartens and schools, they must have a GP. Depending on the age of the child, he or she must undergo preventive examinations – for example, up to the age of 1, examinations must be carried out every month, but as children grow up, these compulsory visits to the GP become fewer. This is done to check that all the mandatory immunisations have been administered, as well as to pass all clinical laboratory tests.
THE DOCUMENTS FOR ADMISSION TO NURSERY, KINDERGARTEN AND/OR SCHOOL ARE AS FOLLOWS:
A health card and a medical note stating that the child is clinically healthy – issued by a GP or another specialist doctor. The best option is to find a GP for your child who will issue the necessary documents after making sure that the child has had all the required vaccinations.
In case your child does not have a GP, you can contact the immunization office of the Regional Health Inspectorate. The doctor at the immunization office will review your child’s records, administer the required vaccines and issue a supporting document.
The main difference is that for your child’s admission to nursery and kindergarten there are additional examinations:
The result of an intestinal pathogen test done no earlier than 15 days prior to enrolment in a nursery/kindergarten.
The result of a blood and urine test.
It is important to note that the health requirements for admission to nursery, kindergarten and/or school are compulsory and identical for all children who wish to be part of the education system in Bulgaria and this includes children of persons with refugee status. They include the results of medical examinations and a document proving that the child has had all the compulsory vaccines from the Bulgarian immunisation calendar. They are free for children and are safe and effective. This is guaranteed by the Bulgarian Drug Agency and the European Medicines Agency (EMA), which have approved the vaccines. These medical products provide a safe environment in which children can communicate and learn.
If you have any further questions, you can always contact Sofia Regional Health Inspectorate on issues related to health requirements and vaccines, the Regional Health Insurance Fund for assistance in finding a personal physician and the National Revenue Agency (NRA) for payment of health insurance for self-insured persons.
The Bulgarian and Ukrainian immunisation calendars are similar, but there are a couple of key differences. The pneumococcal vaccine is not compulsory in Ukraine, whereas it is in Bulgaria. The polio vaccine in Ukraine is a live vaccine, whereas in Bulgaria a killed vaccine is administered. There is also a difference in the number of vaccines administered for some diseases, and small differences in the age of administration, as indicated in the table below.
To find out your child’s immunisation status you should see your GP, whether you are a Bulgarian citizen or a person with refugee status. In case you have not chosen a GP, you can go to the Regional Health Inspectorate (RHI) in the nearest regional town to have the vaccines administered there. At the Regional Health Inspectorate you should present an original medical document with an accompanying translation into Bulgarian (if available), where all vaccinations administered to your child in Ukraine are reflected. You can also use a photo sent via Viber. In this case it will be necessary to administer only the immunizations that are missing by preparing a personal immunization plan.
As regards a child’s immunization status there can be three scenarios. If the child is fully unvaccinated, then he/she must be given all of the vaccines according to the immunization calendar. If the child is partially vaccinated, it must be ascertained which of the vaccines have and which haven’t been administered against the immunization calendar. If the child has been given all the necessary immunizations for his age in Ukraine, it is only necessary to provide documentary proof of this. These medical documents do not have to be original, copies can be provided, you can even use a photo of the documents in which the basic health information is certified by a doctor.
There were many questions from those attending the meeting or signed up for the webinar about the topics discussed. Below are the questions that concerned issues outside the scope of the presentation that needed further clarification from Dr. Miroslav Spasov.
There was a question about the format of medical referrals. Dr. Spasov explained that the GP issues a medical referral which is uploaded into the system (the so-called e-referral) and the relevant medical specialists or people who perform the tests download and report it.
Is there a special HIV programme for refugees? Answer: Of course. There are confidential doctor’s offices where people with refugee status can be counselled and screened for AIDS and prescribed treatment. The examination is free of charge for the patient.
As a reminder, please note that Astra Forum will take care to provide information about doctors willing and able to examine Ukrainian citizens. This is an ongoing initiative and participants in the webinar who need assistance with this issue will receive emails with information very soon.
There was a question related to the administration of a second dose of Synflurex, which is an anti-pneumococcal vaccine and protects against a variety of serious illnesses such as meningitis, sepsis, bacteremia (bacteria in the blood), as well as ear infection and pneumonia. The vaccine is not available and the question was whether the child could be enrolled in a kindergarten. Dr. Spasov replied that the child he can be enrolled in a kindergarten and the GP would record the first administered dose of the vaccine and indicate in the health card that a second dose is due. In this case, no one can refuse to enrol the child to a kindergarten, Dr. Spasov said.
If health insurance has not been paid for a year, does it have to be paid for the whole period or can it be paid partially to restore health insurance rights? The entire amount must be paid, Dr. Spasov replied and specified that in the case of emergency care (which is an inalienable right of everyone), upon discharge from the hospital, the missing insurance would have to be paid or the treatment would have to be paid for at market prices, which are much higher.
HEALTH INSURANCE
There was also a question about whether health insurance covers the cost of routine tests for blood, urine, cholesterol. Dr. Miroslav Spasov clarified that these tests are covered when an electronic referral is issued by the GP and are completely free.
There was a question with regard to recognition of disability and Dr. Spasov explained that the authorities in Ukraine and Bulgaria need to be consulted about whether a patient’s disability group is automatically recognized or whether he or she should to go through the procedure for applying for disability in the Republic of Bulgaria. It is not a complicated procedure, everything is done electronically after submitting all the medical documents and it takes about a month to issue a decision of the Territorial Expert Medical Commission. Different disability groups enjoy different types of social benefits whereas the benefits vary according to the degree of incapacity for work.
One of the issues was related to the refusal of the GP (personal physician) to accept new patients. The GP said that there were too many patients already registered. Answer: There is no upper limit for the number of patients a GP can see, if the medical practitioner in question is overwhelmed with too many people and work, he can appoint another health care professional (nurse or other doctor) to assist him. That is, the GP has no right to refuse to sign you up and provide medical care. Dr. Spasov recommended that in case a doctor persisted in refusing to sign up a patient with his practice, another doctor in the vicinity should be sought.
On the website of the National Health Insurance Fund all the procedures and tests that are covered by the health insurance package can be reviewed under the section “Services for citizens”. All the services that are covered by health insurance are listed there.
The first health insurance booklet is issued free of charge. If the official document is lost, a fee of BGN 4,95 should be paid to obtain a new one.
Health insurance does not cover an extensive package of dental services. For children health insurance includes two fillings, one tooth extraction with anaesthetic, one tooth extraction without anaesthetic and periodontitis treatment on an annual basis. For adults the package is even smaller.
Dr. Spasov spoke about the intensity of visits to the GP in connection with annual preventive check-ups for children. For children aged up to 1 year compulsory check-ups are carried out every month with the respective immunizations, as well as consultations on the child’s nutrition, anthropometry, information on the child’s upbringing and clinical examination. For children aged between 1 and 2 years, preventive check-ups are carried out every 3 months. Children aged 2 to 7 years attend these examinations twice a year. The first one takes place during the first six months of the year, the second one – in the second half of the year. Children aged 7 to 18 have a compulsory preventive check-up every year, usually at the beginning of the school year. All Bulgarian citizens aged 18 or over are entitled to an annual check-up.
An e-referral for a speech and language therapist can be issued by the GP, however, this should be discussed with the GP, because some doctors work with the NHIF, while others don’t.
Dr. Spasov also made it clear that it is not necessary to carry the health insurance booklet in order to receive medical care, but it is good to have it at hand together with the ID card whenever one goes out.
The NHIF also covers more expensive medications for chronic illnesses. This is the case of cancer patients, patients with diabetes, and drugs that prevent blood clotting, etc. After going through tests that confirm the disease, the GP schedules a consultation with the relevant specialist, and the patient gets a treatment proposal in the form of an electronic prescription booklet. It is electronic and is different from the health insurance booklet. In the electronic booklet the GP writes out the medication for chronic illness in one-month and three-month prescriptions. With a three-month prescription one can visit the pharmacy once a month during the quarter to obtain the medicines, instead of getting all the medicines at once or visiting the GP each time.
GPs make home visits only on urgent occasions. For example, they visit patients who have difficulty moving, or children whose condition has deteriorated seriously, rather than patients with for minor colds or other minor complaints that are not urgent.
Childbirth (as well as the management of labour) is completely free in this country, unless you wish to choose a team to carry out the procedure (rather than the doctor and team on duty at the time) – this is charged extra. Pregnant women during pregnancy and for 45 days afterwards are exempt from paying the fee for the visit to the GP, to the specialist who manages the delivery, and the hospital stay during the delivery.
The GP makes a home visit within the first 24 hours of the mother and baby being discharged from hospital. This is regulated by law and is not charged extra. This is done so that the newborn does not have to be taken to hospital (and risk getting sick from different types of infections) and to facilitate the parents in this exciting new event in their lives. Enrolling the baby at the GP’s practice can also be done by the father, Dr Spasov explained.
