Healthcare as Investment · 2021. 6. 25. · Although Bulgaria has strongly increased healthcare spending, ... in ly ce rus dy n lta rg ce s a ium l ia m rk y EU ia ia tia d kia ry

Report of the Healthcare Committee of the

American Chamber of Commerce in Bulgaria

Healthcare as Investment

May 2021

1

+ Intro and objectives of the report

+ Importance of investment in healthcare

+ Holistic view on healthcare as investment

+ Cost optimization potential & smart spending in healthcare

+ Optimized funding models

+ Role of the industry as key contributor

+ Conclusion and recommendations

Table of contents

2

Intro and objectives

of the report

3

The report aims to assess the current state of the HC system in Bulgaria and illustrate the long-term benefits of its optimization

INTRODUCTION AND OBJECTIVES

Background

The impact of

delayed or insufficient

investment in

healthcare results in

indirect increases in

Healthcare costs, as

well as long-term

decrease in labor

productivity and

GDP output

Investment in

Healthcare needs to be

on the strategic

agenda of every

government to put

necessary focus on

people’s health and

has become an absolute

necessity to ensure long-

term and sustainable

economic growth

4

Higher GDP

per capita

Investment in Healthcare has become an absolute necessity to ensure long-term and sustainable economic growth

Source: OECD, Eurostat, IQVIA

Background

INTRODUCTION AND OBJECTIVES

Increased labor

productivity

Increased ratio

of workers to

dependents

Lower child

mortality

Improved

adult health

and nutrition

Larger

workforce

from increased

survival and later

retirement

Improved

child health

and nutrition

5

Importance of investment

in healthcare

Expand equitable access to modern,

comprehensive, quality-, people- and

community-centered healthcare

7

Despite a significant progress, the Bulgarian healthcare system still needs an updated comprehensive investment strategy

IMPORTANCE OF INVESTMENT IN HEALTHCARE

Sources: Eurostat, OECD, NHIF, NSI, IQVIA

Summary

1,637

523*

2003 2019

In order to reverse the pattern, we need structural changes – increased investments in healthcare, coupled with

comprehensive strategies to target these investments to the areas that have the highest impact

healthcare spending

more than 3 times

years of life

expectancy Poor scoring compared to EU average on

• Life expectancy: 75y (BG) vs. 81y (EU)

• Amendable mortality (per 100k): 427 (BG) vs. 256 (EU)

• Infant mortality (per 1,000): 5.8 (BG) vs. 3.8 (EU)

• Access to healthcare

Worsening demographic trends

• Ageing population: 2y avg age increase in a decade

• Growing old age dependency ratio: 50% increase from 2010

• Suffering working population

Healthcare spending

• Growing healthcare needs

• Extremely high OoP spending close to 40%, placing spending ceiling

• Rising pressure on the system

Healthcare spending can possiblyreach up to 50% of the disposable income of the working population by 2030

&

The Bulgarian healthcare system has

experienced notable progressfor the past 20 years, increasing

However, Bulgaria is currently caught

up in a vicious circle of

71.7

75.0

2000 2018

*EUR PPP per capita

8

Although Bulgaria has strongly increased healthcare spending, outcomes are still to catch-up w/ EU – structural changes needed


*Out of pocket; **2017 data

Source: IQVIA, OECD iLibrary

Country profile – Bulgaria

53.4%46.6%

Inpatient 4.1%

Outpatient 5.0%

Pharmaceuticals 32.7%

Dental care 1.6%

Others 3.1%

2005

2017

+200%

5.6% 0.3%

Low-income vs High-income unmet needs

422

90

254

94

Mortality

(per 100,000

inhabitants)

Child

vaccination

(%)Bulgaria

EU

• Increase in healthcare spending

highest among regional peers

• However, OoP* spending still

among the highest in EU,

damaging therapy access

• As a result, although outcomes

have significantly improved over

recent years, Bulgaria still lags

in:

– Effectiveness

– Unmet needs

• Hence, to change direction,

structural changes/ reforms

needed

Overview Health system & Accessibility

Yearly health spending Unmet needs statistics

OOP Spending in Bulgaria** Effectiveness

9

Life expectancy at birth was 71.7 years in 2000, and increased

to 75 in 2018

Total spending for healthcare per capita increased

substantially in the last years

The life expectancy of people in Bulgaria has improved and spending for healthcare per capita continues to grow


*Compound growth rate

Source: The World Bank, World Development Indicators; OECD

Health status and health system

71.7

72.6

73.5

74.675.0

20

18

20

15

20

00

20

05

20

10

75YEARS

20

03

20

04

20

08

20

12

20

05

20

07

20

06

20

10

20

09

20

11

513

20

16

20

13

20

14

20

15

20

17

20

18

20

19

846

1,637

1,178+8%*

Voluntary

Compulsory

Per capita spending for healthcare (EUR PPP)Life expectancy at birth, years

10

However, there is still catching-up to do with the rest of the EU in terms of health outcomes and thus life expectancy


Source: The World Bank, World Development Indicators

Life expectancy in the EU

83.5 83.482.9 82.9 82.9 82.8 82.6 82.5 82.3 82.3

81.9 81.9 81.8 81.8 81.7 81.5 81.5 81.3 81.0 81.0 81.0

79.178.5 78.2

77.7 77.4

76.2 76.075.3 75.1 75.0

No

rwa

y

Ita

ly

Ice

lan

d

Po

lan

d

Cyp

rus

Sp

ain

Fin

lan

d

Fra

nce

Sw

ed

en

Ma

lta

Ire

lan

d

Lu

xe

mb

ou

rg

Gre

ece

Neth

erla

nds

Bu

lga

ria

Au

str

ia

Be

lgiu

m

Po

rtu

ga

l

Slo

ve

nia

Un

ite

d K

ingd

om

Den

ma

rk

Ge

rma

ny

EU

Esto

nia

Cze

ch

ia

Cro

atia

Slo

va

kia

Hun

ga

ry

Lith

ua

nia

Rom

an

ia

La

tvia

Life expectancy at birth, years, 2018

11

To do this catch-up, additional investment in healthcare is necessary to reach at least average EU levels


Source: The World Bank, World Development Indicators; Eurostat

Healthcare spending

1,637

7.6

0

1

2

3

4

5

6

7

8

9

10

11

12

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

5,500

DE

U

HU

N

PR

T

EUR

CZ

E

MLT

DN

K

ITA

IRL

% of GDP

SW

E

AU

T

NLD

LU

X

BE

L

FR

A

FIN EU

ES

P

SV

N

CY

P

LT

U

ES

T

GR

C

SV

K

PO

L

HR

V

BG

R

LV

A

RO

U

Share of GDP

EUR PPP per capita

Per capita spending

remains comparably low,

with the EU average being

EUR 3,110however, healthcare

spending occupies a

substantial part of the GDP

Per capita spending for healthcare (EUR PPP); % of GDP, 2019

12

This high portion of out-of-

pocket spending deepens

the issue of inequality and

accessibility to basic health care,

which worsens overall results

Bulgaria has

exceptionally high

39.3% out of pocket

spending, the 4th highest in

the EU, following Cyprus,

Greece and Latvia

… and there is not so much room for filling that gap through further out of pocket payments


Source: The World Bank, World Development Indicators; OECD

Total spending for healthcare

0

5

10

15

20

25

30

35

40

45

50

55

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

5,500

DN

KEUR % OOP/total

DE

U

SV

N

CZ

E

LU

X

AU

T

SW

E

NLD

LV

A

BE

L

FR

A

IRL

PR

T

FIN

MLT

ITA

ES

P

CY

P

LT

U

ES

T

GR

C

SV

K

BG

R

PO

L

HU

N

HR

V

RO

U

Per capita spending for healthcare (EUR PPP), 2019

13

171177185189192196202203203211218226229236237239243244245

256264

323348

371405412

427501

518535542

Spain

United Kingdom

Malta

Cyprus

Slovenia

Sweden

Italy

Denmark

Norway

Belgium

Iceland

EU

France

Netherlands

Austria

LuxembourgIreland

Portugal

Bulgaria

Greece

Poland

Finland

Germany

Hungary

Czechia

CroatiaEstonia

Slovakia

RomaniaLatvia

Lithuania

Such an improvement will help Bulgaria further reduce amenable mortality* rates

Source: Eurostat

Avoidable and treatable mortality

Amenable mortality per 100,000 inhabitants, 2017

• Despite the increasing spending on healthcare, amendable

mortality is nearly twice as high as the EU average

• The most important contributor is the persistently high

mortality from cardiovascular diseases (CVDs), as well as

cancer:

Stroke more

than

4 times than the

EU average

Hypertension

more than

4 times than the

EU average

Ischaemic heart

disease

1.5 times greater than the

EU average

• If Bulgaria could reduce at least CVD mortality to the EU

average, it would push all-cause mortality below the EU

average

*Amenable mortality is defined as premature deaths that could have been avoided through timely and effective health care

14

Ø EUR 893.9% of total spending

Ø EUR 342.6% of total spending

While prevention plays a major role, it remains underdeveloped within the local healthcare system and investment strategy


*According to NHIF data

Source: Eurostat, WHO, NHIF

Spending on prevention

• Improvements in CVD prevention and

treatment are possible and could have a

large impact on population health

• However, the frequency of preventive CVD

check-ups remain low: just 38% of the

population in 2018*

A substantial proportion of deaths could

be prevented by tackling behavioral risk

factors and strengthening primary prevention

Average yearly spending on prevention per capita

15

The population over working age will continue to

increase, contributing to potential economic losses

41.9YEARS

Early age prevention is even more important in the context of an ageing population to contain economic losses


Source: NSI

Ageing population

measures the ratio of the number of persons aged 65 and more

per 100 persons aged 15-64 years

40.3 43.5

43.9YEARS

42.1 45.7

2010

2019

2425

26

31

33

20152000 2005 2010 2018

Average age of the population Old age dependency ratio

The average age of the Bulgarian population is growing steadily

16

Moreover, further reducing infant and child mortality would sustainably impact economic development indicators


*Children died before reaching one year of age

Source: Eurostat

Infant mortality

Infant mortality*, deaths per 1,000 live births• Infant mortality in Bulgaria fell steadily

for the last 30 years

• However, in 2019 it is still the 2nd

highest infant mortality rate in the EU

• Prenatal care practices and

screening/prevention programs from a

very early age have the potential to

reduce the mortality rate further

14.8

1.6

1990

Estonia

9.4

3.4

2010

EU average

5.8

5.6

2019

Romania

Bu

lga

ria

2019 E

U • In turn, this will have a sustainable

effect on the country’s economic

development through improving the

demographic situation

17

The current model places the Bulgarian healthcare into a vicious circle, structural changes are needed to break it


*People with 18-65 years of age; **People 65 years or older for 100 people 15-65 years

Source: IQVIA, NSI, OECD;

Future outlook

2020 2030 ...l

Current model results in:

• Low life expectancy

• High amendable

mortality

• Still high infant and

child mortality

• Lack of sufficient

prevention

2,700EUR

6,360EUR

6,885EUR

If the model persists:

• Excessive amount of

healthcare costs per

capita, compared to

average income

• Increasing disproportion

of dependable people

and affordabilityEUR 11bn total spending EUR 26bn total spending EUR 26bn total spending

4.2 million

non-dependable people*

4.2 million

non-dependable people

3.9 million

non-dependable people

34.3 dependency ratio** 38.48 dependency ratio

EUR 9.200 avg. gross salary EUR 18.000 avg. gross salary

Per capita spending for healthcare development

Need for fundamental and structural changes

18

Holistic view on

Healthcare as Investment

Increased investment now = substantial cost

savings tomorrow

Explore solutions on how to meet

future needs in healthcare to save lives and

enhance efficiency

20

We offer a few examples of necessary steps and policies as means to save costs and, potentially, lives

HOLISTIC VIEW

Sources: Eurostat, IQVIA, NHIF, Bulgarian Onco Registry, *Medinfo, **Strengthening health systems through smart spending - EFPIA 2020 report, International Diabetes Federation

Summary

Comprehensive prevention strategies, including active promotion of vaccinations, limit the onset of preventable diseases

e.g., HPV vaccinations can generate BGN 110m* contribution to GDP in a year

Active screening campaigns catch diseases in their earliest stages

e.g., colorectal cancer screening could lead to 16% reduction of incidence rate and 26% reduction of mortality rate**

Prevention & vaccination

Screening

Use of innovative medicines as early as possible can save preventable complications in the future, and hence costs and lives

e.g., innovative diabetes treatments could save up to BGN 250m by reducing preventable complications

Innovative medicine3

2

1The implementation of

screening and prevention

strategies, and the use of

innovative medicine is a

central

instrument to

save costs and

potentially lives

Investment alone is not sufficient - such campaigns need to be accompanied by effective communication to

raise awareness and dispel misinformation (е.g. around vaccination programs)

21

Implementation of screening and prevention strategies, and the use of innovative medicine are an important step to sustainability

HOLISTIC VIEW

Systematic approach

Improve quality of

health care and patients’

health

Tackle extensive

inefficient healthcare

spending

ScreeningPrevention/

Vaccination

Innovative

medicine

22

While securing investment is essential, the institutions should also play an active communication role among the population

HOLISTIC VIEW

Systematic approach

Effective

communication

important to:

› Raise awareness for the importance

of the topic

› Dispel misinformation, e.g.

vaccines

› Encourage responsible behavior

ScreeningPrevention/

Vaccination

Innovative

medicine

23

The most cost-effective way of achieving good health is often to prevent the onset of the disease as early as possible

PREVENTION

*HPV = Human papillomavirus, **SDR = standardised death rate

Source: Eurostat, WHO, NHIF

Example: the case of HPV*

• A rising challenge, both globally, and in Bulgaria, is the

increasing cancer mortality

• Cancer is a leading contributor to Bulgaria’s high amendable

mortality rates

• While vaccination against HPV is free, and initial coverage was at

30% in 2012, it fell to currently less than 7%

• Vaccination is highly recommendable in case of high prevalence,

such as in Bulgaria

• However, there are no government-organized plans and

awareness campaigns to promote HPV vaccinations in the country

HPVInfection with some types of the

Human papillomavirus is the

greatest risk factor for cervical

cancer, causing more than 85%

of its incidence

Cervical canceris the 2nd most common cancer

in women aged

15 to 44 years in Bulgaria

Each yearan average of

369 women are dying from

and

1,112 are newly diagnosed

with cervical cancer

in Bulgaria

SDR**for cervical cancer in Bulgaria is

9.4 per 100,000 women, more

than double the EU average

EX

AM

PL

E:

CE

RV

ICA

L C

AN

CE

R

24

A broad vaccination against HPV has the biggest potential in terms of health outcomes, as well as cost-savings

PREVENTION

Source: IQVIA, NHIF, Bulgarian Onco Registry, Medinfo

Example: the case of HPV

Investment in

vaccination against

HPV can lead to

BGN

110 million

contribution

to GDP

Vaccination: BGN 26mfor wide vaccination of girls, including costs for vaccines and their administration

Economic cost estimate for different alternatives for one year

1

Screening: BGN 69mfor screening of women between 25-65 years, including costs for medical checks, tests, one-time screening organization and coordination; excluding costs for treatment of diagnosed cases

2

Passive behavior: BGN 133mincluding minimum cost of treatment for patients at each stage and the economic losses from premature death

3

25

Systematic screening can detect cancer early on and thus significantly reduce avoidable mortality

SCREENING

*last available data for 2017; **estimates based on UK data

Source: Strengthening health systems through smart spending - EFPIA 2020 report; Bulgarian Onco Registry

Example: screening for colorectal cancer

• The colorectal is the 2nd most common cancer death cause in males – 9%, and 3rd for females – 10.2%* in Bulgaria

• As few as 10% of the yearly diagnosed patients are diagnosed in Stage I of the disease, while between 40-50% in Stage III/IV

• Prevalence and death rates in Bulgaria are higher than the EU average, while the 5 years survival rate is as low as 45.2%

• Treating colon cancer at stage IV instead of I is 4 times more expensive**, while survival rates much lower

Onset of

disease

Discovery

through

screening

Disease

discoverable

through

screening

Disease discoverable by

patient – symptoms; late

stage for treatment

A B C

Death

Critical point

26

A screening with a 72% participation rate in the Spanish Basque country generated nearly EUR 100m savings

SCREENING

Source: Strengthening health systems through smart spending - EFPIA 2020 report

Example: screening for colorectal cancer

CASE: SPAIN, BASQUE COUNTRY

COLORECTAL CANCER SCREENING PROGRAMME

-16% in cancer incidence

-26% in cancer mortality

EUR 93 Millionnet savings through saved costs on

treatment and prevented economic

losses through saved lives

The Basque Country has a

population of 2.2 million

Target for the screening were

586,700 residents

72% achieved participation rate

27

Adoption of innovative pharmaceuticals can also avoid unnecessary costs in other parts of the healthcare system

INNOVATIVE MEDICINE

Source: IQVIA; Strengthening health systems through smart spending - EFPIA 2020 report

Access to innovative medicine

127 154

307

158

298

436

349

566

252 269

522

414 425 439504

711

521445

682634

512436 452

687

660

823 812

517

398

797

584

812752

806

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

0

20

40

60

80

100

120

140

160

Tim

e (

days)

Nu

mb

er

of

pro

du

cts

# of Products with accessibility date Maximum delay Minimum delay Mean (mean days)

• Bulgaria still has a lower

rate of availability of

medications, as well as

one of the longest time to

availability (the days

between EMA marketing

authorization and the date

of availability to patients)

• Innovative

pharmaceuticals play a

crucial role in improving

the health of patients, and

can avoid unnecessary

costs in other parts of the

healthcare system

Time to availability (2018) of innovative medications

28

Diabetes can serve as an example of the potential impact from the early introduction of innovative treatments

INNOVATIVE MEDICINE

*Excluding cost of medicines

Source: Strengthening health systems through smart spending - EFPIA 2020 report; International Diabetes Federation

Example: diabetes costs

9%Of the total health

expenditure in the

EU is spent on diabetes

75%Of those costs are triggered

by preventable diabetes-

related complication

The systematic use of already available innovative medicines could contribute to

reducing mortality rates, as well as improve overall outcomes and hence lower future

costs. Still, only 6.2% of diabetes expenditure within the EU goes to medicines.

Diabetes is

BGN 550mDiabetes related expenditure in

Bulgaria yearly

60%Allocated to hospitalizations due

to complications

BGN 250mCould be potentially saved* through

prevention and the adoption of

innovative medicine to help reduce

preventable complications

the main cause

of blindness and

kidney failure

the 2nd most common

cause of amputation

caused by lack of prevention,

early diagnostic, and insufficient

and timely control of the disease

29

Cost optimization

potential & smart

spending in healthcare

Implement smart strategies and policies for

a sustainable and predictable healthcare

system

31

Healthcare

infrastructure

Loss of

exclusivity and

horizon scan

Reimbursement

spending

Digitalization

Various cost optimization opportunities exist to help sustain the overall healthcare spending

COST OPTIMIZATION POTENTIAL

Sources: NSI, OECD, Eurostat, IQVIA

Summary

• Relatively high density of doctors with 4.2 per 1,000 inhabitants

• Second lowest number of nurses in the EU

• Ageing healthcare personnel

• Fragmented regional distribution, increasing migration

• Weak outpatient care

• Inefficient use of medical devices and procedures

• Address fragmented distribution across the country,

increasing migration & ageing talent

• Availability and utilization of medical devices and

specialists

• Active cost control – UK NHS as an active example

• More than BGN 30m per year freed up resources through cost

reduction from loss of exclusivity

• Reallocation of resources to new or so far not affordable

higher-cost therapies

• Analysis of upcoming loss of exclusivity

• Horizon scan of upcoming innovative medicine

• Currently BGN 42m per year spent on reimbursed medication

<3 BGN

• Reallocation to otherwise unaffordable higher-cost therapies

• Optimization of reimbursement policies, e.g., low-cost

medicine

• No comprehensive approach towards digitalization

• Cost-savings throughout the entire healthcare system with the use

of digitalization

• Possible digitalization initiatives: telehealth, digital

patient records, e-prescriptions, and advanced data

analytics

Possible sources of optimization Possible initiatives

There are several potential sources for cost optimization to support targeted strategies and to sustain

the needed overall increase in healthcare investments

32

Allocation of already existing funding could be optimized, and savings could be achieved by first focusing on four areas


Cost optimization opportunities

Understanding

and addressing

inefficiencies in

hospital spending

and spending

distribution

Optimization/

reallocation of

reimbursement

spending

Loss of

exclusivity

potential and

horizon scanning

of innovative

medicines

Digitalization

possibilities in

healthcare and

cost-savings

potential

By identifying

inefficient spending

and reallocating these

resources, significant

improvements in patients’

health outcomes and

quality of care could be

achieved

33




Optimization/

reallocation of

reimbursement

spending

Loss of

exclusivity

potential and

horizon scanning

of innovative

medicines

Digitalization

possibilities in

healthcare and

cost-savings

potential

Understanding

and addressing

inefficiencies in

hospital spending

and spending

distribution

34

+ Bulgaria has a relatively high

number of practitioners, being in

the leading 10 countries in the

EU with 4.2 doctors per 1,000

inhabitants

- However, 63% of all doctors are

of more than 51y of age

- Notable fragmentation in their

distribution across the country

- In contrast, the country has the

second lowest proportion of

nurses in the EU, twice as little

as the EU average

- The average age of all nurses is

also notably high – 55y

Understanding the structure of healthcare provision and availability in Bulgaria is essential for its cost optimization

HOSPITAL SPENDING AND DISTRIBUTION

* Or latest data available

Source: Eurostat

Medical infrastructure

Doctors and nurses per 1,000 inhabitants, 2018*

0

2

4

6

8

10

12

14

16

18

2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0

BULGARIA

ESTONIA

SWEDEN

DENMARK

Practicing doctors per 1,000 inhabitants

Pra

cti

cin

g n

urs

es

pe

r 1

,00

0 in

ha

bit

an

ts

BELGIUM

HUNGARY

GERMANY

CZECHIA

SPAIN

CROATIA

ITALY

CYPRUS

LATVIA

LITHUANIAMALTA

NETHERLANDS

AUSTRIA

POLAND

UNITED KINGDOM

ROMANIA

SLOVENIA

EU

EU average: 3.6

EU average: 8.4

35

Vidin

3.54

Pleven

6.22Montana

3.50 Vratsa

3.71

Sofia

3.98

Sofia city

5.12

Lovech

3.82

Pernik

2.92

Kyustendil

3.47

Pazardzhik

3.65

Blagoevgrad

2.96

Plovdiv

5.10

Stara Zagora

4.05

Veliko Tarnovo

3.19

Ruse

3.71Vidin

279

Silsitra

2.75

Dobrich

2.70

Varna

5.06

Burgas

3.33

Shumen

3.00

Razgrad

2.91

Targovishte

2.93

Sliven

2.96

Yambol

2.79

Haskovo

2.92

Kardzhali

2.53

Smolyan

3.08

The workforce is challenged by a fragmented distribution and a persistent migration problem


Source: NSI, OECD, Eurostat


250-300 doctors

on average leave Bulgaria yearly

due to low recognition and low pay

at home, which accelerates the

shortage of medical personnel

Medical specialists per 1,000 inhabitants, 2019

Gabrovo

3.89

2.53 6.22

It is, therefore, essential to take necessary

action to tackle the persisting problems and

negative trends:

• Provide regional incentives

• Support educational initiatives

• Raise salaries for paid specializations

36

Hospital care remains dominant mainly due to weak primary and outpatient care causing unnecessarily high costs


Source: Eurostat


4,900

4,525

4,199

20182012 2014

5.9specialists to GPs ratio

3.1specialists to GPs ratio

GPs are supposed to act as gatekeepers to the healthcare system, being the first point of

contact

Low concentration of GPs, lack of availability and often wrong incentive elements result

in a weak primary care system and thus high dependency and over-reliance on

inpatient care

Ratio of general practitionersNumber of general practitioners

37

Primary care and outpatient accessibility need to be drastically improved to reduce avoidable inpatient care


Source: NHIF, Eurostat, OECD


6.0

5.0

7.0

8.0

201820172011 20132010 2012 2014 2015 2016

Bulgaria

EU

342258

167170

20182009

Bulgaria

EU

Cost-saving

potential

• Bulgaria takes the first place in the EU when it comes to hospital beds, as well as hospital discharges per capita

• Compared to outpatient care costs, inpatient care takes up twice as much from the total spending; in contrast, on average in the EU, those are equal

• 20% of all hospitalizations could have been avoided and conducted in outpatient settings

• Hospitalizations are often the result of the limited number of referrals in primary care

Yearly hospital discharges per 1,000 inhabitantsNumber of hospital beds per 1,000 inhabitants

38

• Both Magnetic Resonance

Imaging Units and Computed

Tomography Scanners have

become more available since

2010

• However, there is a limited

understanding of the

maintenance efforts of medical

devices across the country

• Disproportionate regional

distribution poses another threat

on general accessibility

• Lack of sufficient data collection

for exact country-wide distribution

When it comes to medical devices, Bulgaria has followed a positive trend, slowly increasing availability of some devices


Source: OECD

MedTech landscape

MRI and CTS Units per 1,000 inhabitants, 2018

0.420.63

0.74 0.73 0.71 0.71 0.790.99 1.04

3.03 2.93

3.223.43 3.42 3.36

3.473.58

3.89

2014 20172010 201820122011 2013 2015 2016

MRI

CTS

39

While density of CTS is comparably high within the EU, they remain vastly underutilized


Source: Eurostat

MedTech landscape

CTS Units per 100tsd inhabitants, 2018

4.063.97

3.893.84

3.513.51

3.332.88

2.432.39

2.031.96

1.911.891.861.841.811.77

1.651.611.591.59

1.420.94

Greece

Italy

Latvia

Bulgaria

Denmark

Netherlands

Austria

Germany

Cyprus

Estonia

Croatia

Lithuania

Belgium

Ireland

Spain

Malta

Slovakia

Slovenia

Poland

France

Finland

Czechia

Romania

Hungary

CT Scans per machine, 2018

13,99711,070

8,4518,451

7,0606,891

6,6696,3646,210

5,2655,2375,191

4,7784,7084,7074,7044,6514,5094,361

3,4852,665

2,166

1,920

Czechia

Belgium

Hungary

Estonia

France

Slovakia

Netherlands

Austria

Spain

Greece

Malta

Croatia

Germany

Slovenia

Latvia

Poland

Denmark

Lithuania

Finland

Cyprus

Italy

Romania

Bulgaria

40

MRI units are a comparably scarce resource, however, even so have an extremely low utilization rate compared to EU countries


Source: Eurostat

MedTech landscape

MRI Units per 100tsd inhabitants, 2018

3.47

2.93

2.87

2.74

2.35

2.07

1.72

1.60

1.48

1.36

1.35

1.31

1.25

1.25

1.21

1.16

1.04

1.03

1.03

0.95

0.92

0.90

0.49

Spain

Cyprus

Greece

Ireland

Germany

Italy

Austria

Finland

France

Estonia

Latvia

Romania

Belgium

Netherlands

Croatia

Lithuania

Slovenia

Bulgaria

Malta

Czechia

Slovakia

Poland

Hungary

MRI Scans per machine, 2018

9,2458,1968,095

7,2826,009

5,7855,4535,3705,288

4,7894,602

4,2994,0634,0403,994

3,6972,841

2,5651,8401,810

1,202

276

Hungary

Malta

Belgium

Croatia

Slovenia

Estonia

France

Slovakia

Spain

Austria

Czechia

Latvia

Lithuania

Germany

Bulgaria

Poland

Netherlands

Greece

Italy

Romania

Finland

Cyprus

41

In the UK, country-wide mandatory costing mechanisms incentivize hospitals to gain transparency and drive value


Source: IQVIA, NHS E&I

Example: Gaining cost transparency

All NHS trustsneed to comply with a

yearly cost

collection based on pre-outlined

costing guidance

Aim towards achieving goals of the NHS Long-Term Plan, as well as tackle

short-term deficits

Transition from using reference costs to a hybrid of patient level cost and

aggregate cost collection, to reach a full patient level cost collection over the

next years

Support the development of new models of care and reduce variation in the

use of resources

Benchmark healthcare providers

Collected data is used on both national and provider levels to:

• identify operational and clinical efficiencies

• informing the national tariff and other pricing discussions

• informing the relationship between provider characteristics, patient characteristics and

cost

42

Bringing transparency and analytics into the spending will help further optimize the costs


Source: IQVIA


Patient level information costing Benchmarking solutionsIntegrated service line reporting

• Gather and analyze patient level information

• De-compose each patient bill for each

hospitalization, gaining understanding of costs

per resource groups and utilization across the

stay

• Utilization of clinical and support staff

• Monitor the financial efficiency of clinical

decisions

• Implement monthly budgetary statements and

service line analysis reports

• Understand profitability of different services

provided, possibility to drill down into details of

activity by individuals

• Compare financial and operational activity

performance with peers across the country to

identify and share clinical and financial best

practices

• Identify patient cohorts suitable for Clinical

Trials

Example: Hospital costing system deployed at over 260 NHS organizations in the UK

43

Instead of reducing costs through internal trading, profitability could be improved by optimizing the whole patient pathway


Source: IQVIA


• Patient level information costing

system has been used to shift a

paradigm from a focus on reducing

costs through internal trading to

being able to look at whole pathway

costs

• Allows for sensitivity analysis how

increases in diagnostic costs can

reduce length of stay and improve

overall profitability of the service

• Behavior and culture changes have

been established

• Systems have been put in place to

monitor diagnostic testing;

meaningful discussion are now

taking place around clinical

variation

• Increased engagement and

understanding of costs

• Understanding patient pathway

cohorts

Reduction of

length of stay

Earlier diagnostic testing

Supports

frailty unit

model

Improved discharge

planning

Case study: Understanding the patient pathway in health care for older people

SEE GETDO

44




Optimization/

reallocation of

reimbursement

spending

Digitalization

possibilities in

healthcare and

cost-savings

potential

Understanding

and addressing

inefficiencies in

hospital spending

and spending

distribution

Loss of

exclusivity

potential and

horizon scanning

of innovative

medicines

45

LoE forecast and the savings potential it will generate are about to have a paradigm shift in the upcoming years

LOSS OF EXCLUSIVITY

*based on 23 European countries

Source: IQVIA

Loss of exclusivity analysis

82%

Great Recession

(2010-2014)

Covid-19

(2021-2025)*

57%

18%

$28bn

43%

$28bn

Small Molecules Biologics

Historically, the

majority of biologic

opportunity has come

from a small number

of high-value

products

In the next 4-5 years there

is a paradigm shift to a

period where a significantly

high number of products will

lose exclusivity

Biologic loss of exclusivity, forecast*EU5 Loss of Exclusivity

Potential (bn USD)

46

Savings capitalisationSavings

opportunity

Outcomes opportunity

• Bulgaria has a substantial

growth in the use of

biologic medications in the

recent years

• If this growth continues, it

is important to keep track

of potential loss of

exclusivity expected in the

upcoming years

• In the 5-year horizon, there

might be significant

savings opportunities to be

capitalized

LoE savings potential for Bulgaria depends strongly on the direction it will move to regarding biologics and biosimilars

LOSS OF EXCLUSIVITY

Source: IQVIA


0

5

10

15

20

25

30

35

40

45

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0

ESTONIA

ROMANIA

DENMARK

UK

NETHERLANDS

SLOVAKIA

ITALY

LATVIA

GERMANY

IRELAND

SPAIN

Biosimilar MS%

FINLAND

AUSTRIA

LITHUANIA

NORWAY

CROATIA

CZECH REPUBLIC

HUNGARY

SLOVENIA

GREECE

PORTUGAL

BELGIUM

POLAND

BULGARIA

Bio

log

ic M

S%

SWEDEN

FRANCE

EU usage of biosimilars in 2020 (bn USD)

47

Indirect savings through price reductions from LoE could be a source for funding of innovation, however, are not sufficient

LOSS OF EXCLUSIVITY

Source: IQVIA market data


BGN 3,298m

LoE2020 Total Rx

BG Market

BGN 130m

Savings potential

BGN 32m

• Based on EU5 market analysis,

LoE accounts for 3-7% of the

total market value

• While 130m BGN are 4% of the

Bulgarian Rx market in 2020, the

market continues to grow, hence

so will this amount

• Assumed potential savings from

price reductions due to LoE

could be re-allocated to

innovation needs

Estimated savings potential for 1 year based on 2020 Rx Market

3-7% 25%

48




Digitalization

possibilities in

healthcare and

cost-savings

potential

Understanding

and addressing

inefficiencies in

hospital spending

and spending

distribution

Loss of

exclusivity

potential and

horizon scanning

of innovative

medicines

Optimization/

reallocation of

reimbursement

spending

49

Significant opportunities exist in the optimization of reimbursement policies in order to improve access to therapies

OUT OF POCKET SPENDING

Source: NHIF, NSI

Optimization/ reallocation of reimbursement spending

molecules of avg. income total expenditure

(432 brands) are reimbursed at

<3 BGN per pack in the Retail

segment by the NHIF in Bulgaria

in Bulgaria1 is what the cost of BGN 3

represents

p.a. can be saved if all reimbursements

<3 BGN are stopped2

Amount can be used instead to increase

reimbursement level for other categories

(CVD and Diabetes) and reduce OOP

burden for patients

1. Average income per person for 2019 of 544 BGN per month (including salary payments, pensions, social payments, other incomes, divided by entire population); 2. Total amount reimbursed in 2019 for all drugs for which reimbursement amount <3 BGN per pack in the Retail segment (110 molecules, 432 brands)

110 0.5%BGN

42m

50




Understanding

and addressing

inefficiencies in

hospital spending

and spending

distribution

Loss of

exclusivity

potential and

horizon scanning

of innovative

medicines

Optimization/

reallocation of

reimbursement

spending

Digitalization

possibilities in

healthcare and

cost-savings

potential

51

Digitalization in healthcare can be an enabler to save costs, improve treatment access and gain effectiveness

DIGITALIZATION

Digitalization initiatives and their benefits

Telehealth • Ease of access otherwise difficult due to regional disbalance and/or scarce resources

• Management and regular check-up of chronic illness

• Telemedicine and healthcare access in the context of a pandemic

Remote monitoring and sensors

• Keeping track of chronic illnesses

• Reducing amenable mortality rates

Electronic patient record• Better accessibility and quality of the full patient history

• Clearer patient pathway

E-prescription• Saving costs and time on both the patient and doctor sides

• Transparency and data collection

E-referral • Ease of access to specialists

• Re-focusing GPs and primary care’s visits, allowing for better outpatient and reduced inpatient care

Data analytics• Identification of high-risk patients

• Prevention of diseases using predictive analytics

• Cost-savings and efficiency gains through patient pooling and analysis

52

Digital healthcare is dependent on the presence of 4 core pillars –Bulgaria has already made progress, but further work is needed

DIGITALIZATION

From IT health to digital health

Digital healthcare pillars

Strategydesign

• Identification of healthcare needs & requirements

• Definition of what the full spectrum of digital healthcare should include (short- mid- and long-term)

• Definition of Data sources and outputs and analytics

• Involvement of key strategic stakeholders

• Design of the overall Digital roadmap until 2030

Legislative basis

• Introduction of electronic patient record and its role in healthcare

• Legal changes which describe rights & responsibilities and set the IT framework

• Data protection and data ownership rights

• Revision of existing legal texts to ensure compatibility/ consistency

IT infrastructure

• Overall technical infrastructure

• Data Warehouse and Data Lake

• Software backbone

• Database definitions and standards

• Data encryption and anonymization

• Peripheral tools/hardware (e.g. plastic cards, readers, etc.)

Systems integration

• Interfaces between various systems & databases

• UIDs to ensure data matching

• Clarification of ownership & responsibilities

While some initiatives are already in place, a successful implementation requires a comprehensive effort as

combination of all pillars, combined with information and educational campaigns to foster effective adaptation

53

Optimized funding

models

Foster potential funding, investments and

transformation to value-based healthcare

55

There are also a number of options to reform the overall healthcare funding model in the longer run

OPTIMIZED FUNDING MODELS

*Multiannual Financial Framework

Sources: Eurostat, IQVIA, OECD, EKIP, European Commission

Summary

There are several options to reform the overall healthcare funding model in the longer run

Systematic change• De-monopolize NHIF

• Various models possible, e.g.:

• Private complements public payer

• Multiple public & private players

• Fully private system

Innovation funds• Establish dedicated

innovative funds

• Innovative funds can be targeted at:

• All innovative medicines

• Certain therapeutic areas

• Selected patients

Taxes• Re-allocate funding to

Healthcare from excise taxes

• Target products hazardous for human health:

• Tobacco

• Alcohol

• Fuel

• 10% reallocation of taxes could contribute close to BGN 550m

EU funds• Leverage EU funds to

finance structural reforms, e.g.,:

• Latest COVID-19 related recovery and resilience package: one-off opportunity of EUR 6.3bn in grants

• other mechanisms within the MFF*, e.g., EU4Health - EUR 5.1bnto EU member states

56

Pressure on healthcare funding not only a challenge for Bulgaria – various examples exist of how others are addressing it


Source: IQVIA, OECD iLibrary

Country overview

Country Payer type Response to funding challenges Accessibility

0%

5%

EU 1.8%

DE 0.5%

FR 1%

CH 1.3%

Universal private

• Via mandatory health insurance, patients have direct access to all levels of care with minimal waiting times

• Payment contributions determined by private market

• Government closely regulates system & subsidizes healthcare for low-income people to ensure accessibility

Switzerland records 1.3% of unmet needs

✓ All citizens have

access to private

healthcare

× Mandatory higher

taxesBG 2%

Universal private or public

• A large number of private and public payers introduced

• Patients can choose between private and public (once private, difficult to go back to public)

• Payment system reformed to close inequalities between private & public as private patients used to be more profitable for doctors

Germany records 0.5% of unmet needs

✓ Patients have a

right to choose

payer (private or

public)

× Preference of

private patients over

public

Unmet needs

Universal public + complementary private

• Private insurance introduced to complement public one – extra funding for the system

• Employers contribute additionally to private system

• Unemployed or socially disadvantaged people still guaranteed access to healthcare

France records 1% of unmet needs

✓ All citizens and

foreigners have

access to

healthcare

× Long waiting times

57

Introduction of a dedicated innovative fund for new innovative medicines could ensure faster and easier market access


Source: IQVIA

Types of innovative funds and funding possibilities

Decrease market access timeline &

improve market access effectiveness

Innovative funds

Fund for all

innovative

medicines

Fund for innovative

medicines in

selected TAs

Fund for innovative

medicines for

selected patients

1 2 3

Possible funding sources for innovative funds

Dedicated

governmental funds

EU recovery funds

Portion of

excise taxation

58

Several countries across Europe serve as an example of successfully introduced innovative funds in the last years


Source: IQVIA

Innovative funds in place

Scotland has a dedicated

New Medicines Fund in place with the

goal to improve access to orphan,

ultra-orphan and end of life medicines

Wales has implemented the

so-called New Treatment Fund to

speed access to newly approved

medicines across all treatment areasItaly has established two innovative

funds to speed up patient access and to

support the reimbursement of innovative

products in specific therapeutic areas

59

Funding can be generated through one-time state contributions or portion of overall dedicated resources to health


Source: IQVIA

Innovative funds in place

Italy ScotlandWales

Purpose Italy has established two funds, to speed up patient

access and to support the reimbursement of

innovative products

Scotland has the New Medicines Fund in place, to

improve access to orphan, ultra-orphan and end of life

medicines

Wales has the New Treatment Fund in place, to speed

access to newly approved medicines

Drug categories

covered• 1st fund: Mainly dedicated to HCV products but

also other products are included

• 2nd fund: Oncology products

Licensed orphan, ultra-orphan and end of life

medicines

All new therapies

Time horizon • 1st fund: 2015 - 2019

• 2nd fund: 2017 - 2019

Until the end of the 2018 calendar year – intention to

continue the fund

From 2017 to 2021

Funding • 1st fund: €500M initially powered by a state

contribution and a portion of the resources of the

National Health Plan

• 2nd fund: €500M as portion of National Healthcare

spend

Funded through a portion of the rebate to the Scottish

Government made by the Pharma Companies

• For 2015-2016 the funding allocated was £85M

• For 2016-2017 the funding allocated was £53M

• £80M over the course of 5 years

• The fund is on top of the provisional budget for

the NHS Wales

Criteria for

inclusionBased on AIFA algorithm: therapeutic need, added

therapeutic value and level of clinical evidence

Licensed orphan, ultra-orphan and end of life

medicines

New medicines recommended by NICE and the All-

Wales Medicines Strategy Group (AWMSG)

Patients’

participation in

HTA process

No YesNo

60

Due to increasing consumption, as well as ascending rates, income from excise taxation on fuel, alcohol and tobacco is continuing to grow

Portion of this income can be used as funding to innovative funds, or, in general, contribution to healthcare spending

Additional funding could be generated through taxes and levies on health-impacting products


Source: EKIP

Income from excise taxation

1,949.3

2,118.22,146.1

2,272.92,315.7

2,393.4

2018 20192014 20172015 2016

261.7

278.5

295.7300.3

310.5 310.9

20192014 20182015 2016 2017

1,787.2

2,082.0

2,304.02,368.6

2,536.2

2,735.4

2014 201920182015 20172016

Fuel, mBGN Alcohol, mBGN Tobacco, mBGN

61

In case the target allocation is 10% of all taxes, additional contribution could be more than BGN 540m


Source: EKIP

Income from excise taxation

40 45 47 49 52 54

200224 237 247 258 272

400

448475

494516

544

2017 20182014 20162015 2019

1%

5%

10%

Could be allocated to:

• Prevention and treatment of

conditions caused by risk

factors

• Innovative funds

• Total healthcare spending

544mBGN

Target allocation of total taxes for fuel, alcohol and tobacco, mBGN

62

The EU is set to increase its long-term budget to help rebuild a post-COVID-19 Europe, stimulus can be allocated to healthcare


Source: European Commission

Recovery plan and EU Budget for 2021-27

EU stimulus package 2021-2027

750NextGenerationEU

Multiannual

Financial

Framework

2021-2027

1,074

Total:

EUR 1,824 bn

Recovery and

resilience facility

package:

• EUR 390bn in grants

• EUR 360bn in loans

Including the

EU4Health mechanism

• EU funds offer a short-term/mid-term funding solution, offering investment in structural reforms

• However, focus should remain seeking for more sustainable ways of funding

63

Bulgaria is set to receive a EUR 6.3bn grant from the COVID-recovery package, so far less than 7% are planned for healthcare


*Loans could be applied for up to 6.8% of a country’s 2019 Gross National Income

Source: European Commission, Bulgaria Recovery and Resilience Facility Package 2021-2027 draft spending plan


Bulgaria Recovery and resilience facility package

2021-2027 & draft spending plan, bnEUR

6.311.5 GrantsLoans*

20%

37%

22%

21%

Innovative

Bulgaria

Green

Bulgaria

Connected

Bulgaria

Fair Bulgaria

(including

healthcare)

<7%Is currently planned for

healthcare initiatives

approx.

EUR 430mcover five specific areas in the draft plan

funding allocated to healthcare can reach

EUR 1bnif ~15-16% of the grants are used

therefor, similarly to Germany and Spain

64

The Bulgarian

government, as well

as companies,

can use the opportunity to access

additional funding for initiatives

highly relevant to the needed

structural reforms

• AmCham is an available partner

to support such projects, incl.

digitalization initiatives

Funds can be used for:

• strengthening preparedness

and response capabilities

• disease prevention and health

promotion in an ageing

population

• digital transformation of health

systems

• access to health care for

vulnerable groups

Governments, companies and other organizations are all eligible to receive extra funds from the EU4Health mechanism


Source: European Commission


EU4Health

is another mechanism within the

MFF 2021-27 stimulus package,

providing

EUR 5.1bn

to EU member states

65

Role of the industry as

key contributor

Integrate healthcare models based on

partnerships for planning, management,

delivery and evaluation of services and

resources

67

The industry also stands firmly as a partner in the process and is ready to contribute to the change

ROLE OF THE INDUSTRY

Source: IQVIA, NHIF, Clinical trials in Bulgaria - KPMG 2018 report

Summary

The industry also stands firmly as a partner in the process and constantly contributes through:

Pharma companies contribute directly to

the public spend on a solidary basis at a level of

more than 20% from NHIF expenses

More than 13,000 people are currently

employed by the industry in Bulgaria

CTs additional impact through:• giving access to patients to latest innovative therapies

• creating employment, educating and retaining talent

• creating additional income for doctors

• generating tax contributions to the state budget

• technology transfer and know-how sharing

Ø 140 CTsstarted each year for the last 5 years, with

Ø 130,000 patientstarget enrollment in CTs starting each year

Close to

BGN 180m market value of clinical trials

& BGN 42m direct contribution to the state budget

Direct contribution to public spend

Employment creation

Clinical trials contribution

68

In the scope of clinical trials, the healthcare system further benefits on critical points, such as cost reduction and accessibility

ROLE OF THE PHARMA INDUSTRY

Source: IQVIA, clinicaltrials.gov

Impact of clinical trials

Access to higher quality treatment for patients (innovative

molecules)

Access to high quality paraclinical investigation for patients

Contribution to the public healthcare system (reduction of the

NHIF reimbursement costs)

Education and professional development

Contribution to the economy (including related taxes)

Technology transfer and know-how sharing

Employment opportunities

Increase of public hospital funds

Retention of medical personnel

Ø 140 CTsstarted each year for the last 5 years,

113 in 2020

~ 95% of all CTsare fully or partially funded by pharma

companies,

92%, on average, are fully sponsored by pharma

companies

Ø 130,000 patientstarget enrollment in CTs starting each year,

for the last 5 years

69

The clinical trials industry contributes close to a fourth of the generated revenues directly or indirectly to the state budget


Source: Clinical trials in Bulgaria - KPMG 2018 report

Clinical trials contribution

Total

1,939

Corporate employee costs

6,773

19,442

Corporate income tax

VAT

7,607

5,059

Ethical committees

and regulatory fees

Personal Income Tax

Estimated market value of CT, 2017 Estimated contribution to the authorities / state

buddget, 2017, tsd BGN

BGN

178m

BGN

42m

70

Moreover, the size and development of the industry leads to growing employment


*Estimate based on company information and expert interviews

Employment in the pharma sector

• All functions within pharma companies

• Clinical research organizations

• Medical technology and devices companies

• Pharmaceutical & Medical Device Distributors

more than

13.000 people

are currently employed by

the industry in Bulgaria*

71

Conclusion and

Call for Action

72

Call for Action (1/3)

CONCLUSION

Investment and Funding

• Increase total Healthcare investment as

10% of GDP to close the gap with average

EU benchmarks

• Increase state investment to reduce

OoP spending to less than 20%, close to

EU average

• Launch a dedicated Innovation Fund to

drive early access to innovative medicines

to patients

• Implement new ways of funding:

• Re-allocate funding from existing taxes

and levies on health-impacting

categories (tobacco, alcohol) towards

investments in healthcare

• Prioritize and channel investments in

Healthcare as part of EU Funds

(Recovery and Resilience facility and

EU4Health mechanisms)

Innovate FundingSpend EfficientlyClose the Gap

• Increase efficiency in healthcare spend,

focusing on Hospital segment

• Introduce transparent cost tracking and

benchmarking among hospitals as first

step

• Conduct regular horizon scan exercise

to estimate and plan potential budget

impact from LoE and new product

launches

73


CONCLUSION

Strategic Priorities to Drive Healthcare Forward

Invest in Prevention and Screening

Stabilize Workforce Dynamics

Advance Outpatient Care

Implement Digital Health1 2 3 4

• Set up government-

supported specific strategies

around:

• Prevention (Vaccination

programs)

• Early screening

• National Cancer

Strategy and set up of a

National Cancer Registry

• Drive awareness and dispel

misinformation through

educational

communication campaigns

(e.g. vaccination)

• Provide comprehensive

incentives programs for

young doctors to remain in

Bulgaria and to address

regional disparities

• Support public/private

partnerships (government,

academia and private

companies) to invest in

medical education

• Channel resources to

address funding gap for

nurses and personnel in

hospitals

• Strengthen provision of

outpatient and ambulatory

care

• Reduce hospital duration

and re-allocate inefficiently

spent resources from

inpatient care

• Set up a Digital Health

Roadmap with clear vision,

priorities and milestones until

2025

• Finalize full implementation

of e-prescription and set up

of EMR

• Revise legislative base to

allow for professional and

publicly funded provision of

telemedicine services

• Harmonize public

databases to allow for data

interconnectivity

74


CONCLUSION

Open up for Public-Private Partnership to drive Healthcare Forward

Healthcare is a

complex topic that requires

a holistic approach and

various capabilities

By combining efforts of

different experts –

innovative projects and

strategic initiatives can be

successfully implemented

Ministry of HealthHealthcare Service

& Analytics Companies

Academia:

Universities

Clinical Research

Organizations

Professional

Associations & NGOs

Pharma CompaniesBulgarian Medical

Association

NHIF

Bulgarian

Pharmacist Union

MedTech

Companies

Technology Companies

Healthcare

stakeholders

Bulgarian Dental

Association

Thank you!

Documents

Healthcare as Investment · 2021. 6. 25. · Although Bulgaria has strongly increased healthcare spending, ... in ly ce rus dy n lta rg ce s a ium l ia m rk y EU ia ia tia d kia ry