Bulgarian population – before COVID-19 and now

Background

The demographic picture in Bulgaria became worse and worse since the democratic changes at the end of the 20th century. Our country was at one of the first positions according to the level of death rate and the rate of population decline. The study aims to analyse the effect of the COVID-19 pandemic on the main demographic indicators in Bulgaria.

Methods

Data from Bulgarian National Statistical Institute were used to analyse population growth and life expectancy and to calculate the death rate, birth rate, infant mortality rate, and the share of people over 65 years of age for 2019 in comparison with 2021.

Results

In 2019 before the onset of COVID-19, the Bulgarian population consists of 6 951 481 people. In 2021 it declines to 6 838 937 people. The decrease in birth rate is not very significant - from 8.9‰ /2019/ to 8.5‰ /2021/. The analysis provides estimates of excess deaths observed during the peak of the COVID-19 outbreak in Bulgaria. The death rate is very much increased - from 15.5‰ to 21.7‰. The increase affects the female and male populations equally - from 19.6‰ for men in 2019 to 23.2‰ in 2021 and from 16.4‰ for women to 20.2‰. The life expectancy shows a certain decrease - from 74.8 years /2019/ to 74.64 /2021/. Correspondingly, life expectancy was reduced for females- by 78.34 - 78.22 and for males by 71.37 - 71.11 years. The level of infant mortality is not changed - 5.6‰. People over 65 years are 21.6% of the total population during the compared period.

Conclusions

The Bulgarian population is very strongly affected by COVID - 19 pandemic. The COVID-19 pandemic has caused a significant number of deaths worldwide but Bulgaria ranks first in the world in terms of mortality rates. Life expectancy decline reflects the impact of temporary epidemic mortality. The impact on children from the pandemic is not very significant for the country. Society should be making major and cost-effective efforts to reduce mortality.

Key messages

• The sharp change in demographic realities has significant effects on the country’s economy.

• The deterioration of natural growth exacerbates the need to increase labour productivity in areas with the fastest declining populations.

Regional differences in Bulgarian population ageing

Background

Europeans are living longer than ever, and the age profile of society is rapidly changing. Despite the observed improvement in public health in the European region, for many people old age is accompanied by a high risk of social exclusion and poverty, limited access to quality health and social services, especially in countries with economies in transition. This poses serious challenges for individuals and society. This report aims to analyse the basic regional differences of ageing in Bulgaria.

Methods

Information from the World Bank Open Data was used to calculate the basic indicators: proportion of people 65+ and ageing index for selected European countries. To estimate the rate of change, the growth of ageing index (in %) was calculated on a constant basis in 1970. The regional differences of ageing for Bulgarian population were analysed based on the National Statistical Institute data. The absolute numbers for regions were regrouped and the main indicators for population ageing were calculated. Analysis and calculation procedures were performed by Microsoft Office Excel 2019.

Results

By 2019, in fourteen of sixteen selected European countries, the ageing index exceeded 100%, and in four countries, it was even over 150%: Italy (174.78%), Portugal (168.70%), Greece (157.89%) and Bulgaria (150.07%). In Bulgaria, the proportion of people 65+ was 21.64% with great differences by regions. The highest proportions were found for Vidin and Gabrovo (29,94% and 29.05% respectively) compared to 19.24% for Varna and 17.70% for Sofia. The ageing index varies from 109.40% for the region of Sliven, 126.38% for Varna and 119.91% for Sofia to 248.63% for Vidin, 248.17% for Gabrovo, and 227.98% for Kyustendil, which are the regions with lower availability of health care.

Conclusions

The profound regional differences in population ageing impose permanent monitoring and directing the regional social and public health policies to avoid unfavourable effects of this process.

Key messages

The change of health status with increasing age is a challenge for the capacity of the health systems, especially for provision of long-term care, to cover the needs of the elderly. It is of utmost importance to develop policies and conditions for long-term and palliative care and for improvement of services and living conditions to ensure a better quality of life.

Difficulties in implementation of the National Health Map in Bulgaria

Background

National Health Map (NHM) of Bulgaria determines the required minimum of healthcare facilities, hospital beds and specialists at different levels of Health System to meet population's needs of healthcare. Its main objective is to adapt structure of the healthcare network to the population health needs ensuring for every Bulgarian citizen an equal access to health services. Through it healthcare resources have been planned on a territorial basis and the national health policy has been implemented. The aim of this report is to analyze the actual availability of healthcare facilities and staff, and compare with the minimum necessary according to the NHM.

Methods

Content and critical analysis of statistical data of the Bulgarian Ministry of Health.

Results

Bulgaria is among countries with relatively low number of general practitioners (GPs) among countries of EU where the range is between 42 and 253 per 100 000 inhabitants. According to the NHM, taking into account administrative division, infrastructure and morbidity, optimum GPs/population ratio is about 67/100 000 while an actual availability is 55.9/100 000. The most serious deficiency is in remote areas where the ratio is between 26 and 32 per 100 000. Quality of primary health care is affected by the fact that 23.89% of GPs are without acquired specialty. Number of practicing nurses in Bulgarian health system is 30% lower than the recommended minimum. Nurses/population ratio is unsatisfactory. Physicians/nurses ratio is not consistent with European standards. Hospital beds are 6.3/1000 which range Bulgaria among five European countries with the highest availability of hospital beds but they are unevenly distributed both on a territorial basis and on specialties.

Conclusions

There is a lack of human resources in Bulgarian Health System and unequal availability and accessibility of health facilities in different regions of the country. Distribution of hospital beds on specialties also must be optimized.

Key messages

National Health Map of Bulgaria determines population needs of accessible outpatient and hospital care, distributes health institutions on territorial bases and implements National Health Policy. Difficulties in implementation of National Health Map are insufficient number general practitioners (GPs), a large proportion of GPs without acquired specialty, inadequate ratio physicians/nurses etc.

Health status and regularity of preventive activities among working population in Bulgaria

Background

Prevention is an important instrument for public health improvement and maintaining workability of active age people. National Health Insurance Fund of Bulgaria (NHIF) finances an annual regular check-up for people over 18 years of age. In addition, working people have access to preventive activities at their workplace. The aim of the study is to explore an actual regularity of preventive activities at active population in Bulgaria.

Materials and Methods

Data were collected by documents review and direct individual self-administered questionnaire, within a larger research project on health of active population in Bulgaria. It includes 326 employees in a study representing different branches, companies and professions. The questionnaire consists of questions about: a) distribution of risk factors, b) knowledge and attitude to prevention as a tool for better health c) types and regularity of preventive activities. Data processing was performed by SPSS v.24.

Results

Three of four respondents have been diagnosed with chronic disease, 49.4% of them suffer from more than one disease. One third of observed people take more than one medicine. Despite NHIF offers free of charge and obligatory annual check-ups, only 46% of study subjects have undergone a preventive examination within the last year, 49.7% - between 2 and 5 years and 4.3% have done so more than 5 years ago or never, which decrease the effectiveness of preventive measures. Visiting regular check-ups is significantly lower for younger age groups (below 44 years; p < 0.05). Relatively large part of people measured blood pressure (88.5%), blood glucose (67%) and blood cholesterol (51.5%) during the last year in relation to any symptoms, but not within the regular check-up.

Conclusions

Study results confirm the current tendency for low coverage of annual check-ups of working population in Bulgaria. Potential of preventive activities is not rationally used because recommended regularity is not observed.

Key messages

Phenomena as polymorbidity and polypragmasia are widely distributed in Bulgarian active population. Potential of preventive activities is not fully used because recommended regularity is not observed. Despite Bulgarian NHIF finances obligatory annual check-up for people aged over 18 years, most people become subjects of medical examination in case of disease symptoms, rather than regular check-ups.

Experts’ point of view on migrants’ health and Bulgarian health system performance

Introduction

Migrants often face serious inequities concerning their state of health and their access to good quality health services. The aim of the study is to analyze the experts' point of view on migrants' health and Bulgarian health system performance in this field.

Methods

Within the TRAIN4M&H project, founded by European Commission, work seminar was organized in Bulgaria in March 2019th. Focus group and facilitated discussion with experts intended to elicit information about significant migrants' health problems was performed. Quantitative and qualitative data were collected through an unstructured interview. Data processing was performed by SPSS v.24.

Results

All participants in the seminar: 22 frontline health professionals (5), law enforcement officers (13), social workers (2) and other professionals (2) were covered. According 60% of participants the health of migrants threatens the health of the host population. The leading health issues among migrants are: infectious and parasitic disorders as a result of bad hygiene (9), psychiatric problems and drug abuse (5), children and pregnant women health problems (3) etc. Most of the experts (77.3%) determine that there is no difference between health care needs of the migrants and Bulgarian population. None of the respondents said that migrants need hospital care mainly. On the opposite, according to experts' point of view they need emergency care (31.8%), primary health care (36.4%) and specialized care (22.7%). The Bulgarian health system provides adequate health care only in some specific cases, according to two thirds of the respondents. As positive results of the health system performance experts point “asylum seekers are fully health insured”, “the treatment of migrants in the centers is free of charge” etc.

Conclusions

In order to establish migrant friendly health system in Bulgaria and to improve the quality of services provided develop and enhance skills of professionals working at local level is crucial.

Key messages

Professionals working at local level with migrants have to be well qualified to face problems in relation to migrants’ health and their access to health care. According to the experts working at local level with migrants Bulgarian health system is not well prepared and provides adequate health care for migrants only in some specific cases.

Health impacts of air pollution in Bulgaria

Background

Air pollution is a major cause of premature death and disease, and is the single largest environmental health risk. Heart disease and stroke are the most common reasons for premature death attributable to air pollution, followed by lung diseases and lung cancer. This report aims at investigation and comparative analysis of air pollution and mortality related indicators in Bulgaria.

Methods

Descriptive study design with content analysis is applied on data from accessible national and international databases and publications - Bulgarian National Statistical Institute and The European Environment Agency. To evaluate the health burden attributable to air pollution were used the population-weighted concentration and the estimated number of attributable premature deaths, and the Years of life lost (YLL) per 100 000 inhabitants in 2016. The Ambient Air Quality Directive defines the PM2.5 Average Exposure Indicator which reflects population exposure to PM2.5 and shows the average concentration at urban areas, calculated as a 3-year average.

Results

In 2015, the level of PM2.5 had to be below 20 µg/m3 in any country. In 2017, concentrations were still above that level in three countries - Slovakia 22, Poland and Bulgaria 24. The largest health impacts in terms of premature deaths and YLL, are observed in central and eastern Europe where the highest concentrations are also observed - Kosovo, Serbia, Bulgaria, Albania and North Macedonia.

The premature deaths attributable to PM2.5 exposure in Bulgaria are 13 100, to NO2 - 1 100 and to O3 - 280. The YLL attributable to PM2.5, NO2 and O3 exposure are respectively 1858, 151, 42. All these levels are very high in comparison with other European countries.

Conclusions

Recognition of the full health and economic cost of air pollution and the benefits of pollution reduction should spur increased use of renewable energy, energy efficiency, and clean-fuel vehicles. This is a necessary investment for Bulgaria's future.

Key messages

Responsibility for, and tools to tackle, many environmental determinants of health lie outside the direct control of individuals or the health sector alone. Wider societal, intersectoral and population-based public health approach is needed.

Roma origin as a factor for high level of adolescent fertility and abortion rate in European Union

Background

Adolescence is a vulnerable phase in human development. Adolescent girls from Roma origin, especially younger girls, are particularly vulnerable because they face the risks of premature pregnancy and childbirth. The study aims to evaluate the association between Roma origin of mothers and prevalence of adolescent fertility and abortion rate in EU member states.

Methods

A correlational study was conducted and data on prevalence of adolescent fertility and abortion among adolescent girls (per 1000 live births) were extracted from European database “Health for all”. The means of variables in different countries were compared and Pearson’s correlation coefficients with share of Roma population were calculated. Data processing was performed by SPSS v.24.

Results

Increasing trend in premature childbirth has been observed in parallel with the increase of share of Roma population within countries, significantly more expressed in South-East member states. The mean adolescent live birth rate in the countries with highest proportion of Roma population was 5.6 times higher as compared to the mean for those with lowest proportion of Roma population. The highest level of proportion of live births to mothers aged less than 20 years was found in Romania (9.8%) and Bulgaria (9.5%). At the same tame proportion of Roma population in those countries is highest: Bulgaria (4.7%) and Romania (2.5%). The relation of adolescent fertility rate with share of Roma population shows significant positive correlation (r = 0.804, with 2-tailed significance p = 0.000). As far as the correlation of abortion among adolescent girls with the Roma origin is concerned, it is inverse and not significant.

Conclusions

Our results indicate significant correlation between share of Roma population and adolescent live birth in EU member states. A holistic approach is needed in which socio-economic development and education of Roma girls leads to further reduction of adolescent childbirth and abortions in EU.

Key messages

Adolescent girls from Roma origin in EU face the risks of premature pregnancy and childbirth more expressed in South-East member states and significant positive correlation for it was found. Bulgaria is the country with highest share of Roma population (4.7%) and in the second place according proportion of live births to mothers aged less than 20 years (9.5%) in the EU in 2015.