A critical shortage of general practitioners threatens the Bulgarian health system, according to a new report by the National Health Insurance Fund (NHIF). 

Lower general practitioner numbers will slow patient treatment pathways and prevention of diseases in the EU’s poorest country. In addition, not enough GPs can lead to delayed referrals of patients to hospitals, risking severe consequences, the latest report shows. With GPs positioned as the gateway to the Bulgarian health system, more serious bottlenecks look certain.

Age is another source of concern, as most GPs are over 51 years old.

“In a few years, this problem will become even more acute,” Dr Nikolay Branzalov, who is deputy chairman of the Bulgarian Doctors’ Union’s board, told Euractiv. Dr. Branzalov commented that there are general practitioners who continue to work at the age of 80. There are only 260 general practitioners under 40 in Bulgaria.

The report highlights another serious structural problem in Bulgarian health care. Bulgaria has the largest number of hospital beds in the EU, but there are not enough nurses to cover them.

Falling numbers

Currently, there are 3,320 general practitioners and group practices in the country with a population of 6.5 million. This means that, on average, there are more than 1,950 patients per doctor. By comparison, Ireland with a population of 5.2 million, has 4,370 registered GPs.

In 2019, the number of GPs was 4,229, so in five years, 909 GPs have closed their practices – some have retired, others have fallen victim to the COVID pandemic.

Between 70% and 80% of medical examinations in the country go through GPs. Each year they perform 30-35 million examinations. GPs refer to specialists for health fund-paid check-ups when needed. People with chronic conditions, such as diabetes or heart disease, visit them periodically to renew prescriptions.

Even for annual preventive check-ups, patients must first see their GP – this GP drought hinders timely referral to specialists such as gynaecologists, urologists, and ophthalmologists.

According to a report from the National Statistics Institute, there are six GPs per 10,000 population. The problem is that they are very unevenly distributed.

“There are large parts of the country, areas where it is almost impossible to find a GP,” Dr Branzalov said.

According to doctors Euractiv spoke with – all requesting anonymity – young medics don’t want to be personal physicians because of the amount of administrative work associated with the role, and the need to be available to their patients 24/7.

There are areas of the country where there are over 3,000 patients per doctor. Targovishte district has the least number of GPs, with 51, in Kardzhali district they are 69, in Vidin 80, and in Sofia 864.

Hurdles in access

To reduce inequalities in access to a doctor, the NHIF has introduced financial incentives for doctors in rural and remote areas. Additional incentives are offered as a lump sum for opening a practice, while the doctor’s family’s rent and transport costs are also covered. So far, these measures are not bearing fruit.

At the same time, paediatricians are not allowed to be personal physicians to patients under the age of 18 if they do not have a speciality in general medicine. Currently, if parents want to bring their child to a specialised paediatrician, they must go through their GP for a referral.

Either way, there is an identical problem with paediatricians; they are few and the majority are at retirement age. The state does not incentivise young doctors to specialise in paediatrics, including not allocating enough centres for training.

No right to refuse patients

By law, GPs have no right to refuse a patient who has asked to enlist in their practice. This would, in theory, lead to unlimited expansion of the patient list. Many personal physicians simply refuse to enrol patients because they are overwhelmed.

“GPs are overstretched precisely because they are woefully understaffed. This is also the situation with nurses,” Ralitsa Ganeva, one of the authors from the Bulgarian Council for Economic Analyses who studied the topic, recently commented.

“We need to think very seriously about how we can bring back, partially even, the doctors and nurses who left Bulgaria. How can we attract them back? We also need to think about whether we can attract students from the Bulgarian diaspora abroad to strengthen the capacity of the system,” Ganeva says.

[By Krassen Nikolov, Edited by Vasiliki Angouridi, Brian Maguire | Euractiv’s Advocacy Lab]

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