Cancer mortality in Bulgaria is growing, while treatment costs double [Advocacy Lab Content]

Bulgaria remains the only country in the EU where the death rate from oncological diseases continues to rise. Patients face financial and organisational difficulties in accessing treatment, even though public funding has more than doubled in the past five years.

The specialised medical research project “Access to Oncology Care” illustrates that an increase in state funding has not improved the results of oncology treatments. The study was supported by the “America for Bulgaria” Foundation, the Association of Bulgarian Insurers and the “Joint Oncology National Network”.

For the past five years, while the number of new cases of oncological diseases per year has remained stable at around 27,000 in Bulgaria, the public treatment cost has increased from 320 million euros to 735 million euros, mainly due to an increase in the costs of cancer drugs.

According to associate professor and oncologist Dr Dimitar Kalev, Bulgaria does not have a good organisational system for the treatment of oncological diseases.

Death rates rising

Nevertheless,  Bulgaria remains the only country in the EU where the death rate from cancer is increasing. Mortality increased from 229 deaths per 100,000 population in 2011 to 242 per 100,000 in 2019 and 247 per 100,000 in 2020.

On average, in the EU, this indicator decreased from 268 per 100,000 people to 252 per 100,000 in 2020, according to data from the European Cancer Inequalities Registry.

The 5-year survival rate of cancer patients in Bulgaria is decreasing and remains much lower than the average in the European Union.

For prostate cancer, survival is 68%, compared to 87% in the EU. For breast cancer, the survival rate is 78% in Bulgaria, against 82% in the EU; for cervical cancer, it is 55% against 64%; for colon cancer, 52% against 60%; and for lung cancer, 8% vs. 15%, respectively.

Bulgaria is a country without effective screening programs, which is why diseases are detected late, usually after the third stage, when treatment is difficult and the outcomes poor.

Patient treatment in other countries

“The patient is always faced with a procedure that is either missing, or not paid for by the state or does not exist at all in Bulgaria, and he must either pay for it or look for it abroad,” says Dr Kalev.

Kalev claims that up to 45% of the patients he consults are patients who intend to be treated in Turkey because they have not found the needed therapeutic procedure in Bulgaria.

The Bulgarian healthcare system does not have strictly regulated procedures and efficiency control and therefore produces such results, the oncologist commented.

Patients pay for their treatments

Public funds are not enough to fully cover the treatment of cancer diseases in the country, and patients are forced to finance their treatment themselves, even when they are insured and have paid their contributions to the state health fund.

“In case of dispensation and follow-up, an additional payment is also almost always required,” according to the study. Even though the follow-up is carried out, its quality is not satisfactory.

Bulgaria pays almost nothing for palliative care, either at hospices or at home care.

Special treatment

For a decade, the National Health Insurance Fund (NHIF) paid different prices to public and private hospitals for the same cancer medicines. In some cases, private hospitals pay up to 10 times more than public hospitals. In both cases, the money is reimbursed by the NHIF.

Bulgarian legislation obliged state hospitals to uphold public procurement processes for the purchase of medicines, while private hospitals bought them after direct negotiation with traders, who, in some cases, are related to them.

The different legal treatment led the European Commission to start infringement procedures against Bulgaria for non-compliance of the national law with the European rules.

From 1 July 2024, private hospitals will no longer be able to use this legal advantage after parliament introduced regulated procedures to determine the prices of the drugs that hospitals buy.

Higher pricing

Over 69% of cancer patients in Bulgaria in the last five years had to pay an average of 750 euros extra for their treatments because the money provided by the state was not enough to cover all costs.

The need for additional funding limited the health care received by 26% of cancer patients, the study found.

Most people paid extra for a surgical operation (56%) at an average amount of around 866 euros. The most common reason is the frequent practice in Bulgarian hospitals for patients to pay extra for the medical team chosen by them in advance.

All Bulgarian hospitals have such a fee which, even though it is voluntary, in many cases, patients are informally required to pay for selecting a medical team for their surgery.

Patients are also required to pay extra if they want to be accommodated in a room with relatively normal hospital conditions.

A total of 41% of patients paid for medical tests themselves – an average of 225 euros, although the state guaranteed free treatment for people who cover their own health fees.

For a biopsy, a quarter of cancer patients paid an average of 135 euros from their personal money. The same number of people also paid for drug therapy, an average of 325 euros.

Although paid by the NHIF, access to highly specialized examinations and imaging, such as computed tomography, nuclear magnetic resonance, PET-CT and various scintigraphy, is also hindered.

In the case of medical devices, an additional payment is almost always required since expensive devices are not fully covered, and others are only partially covered by the NHIF – including sets for laparoscopic operations, canvases for abdominal wall plastic, automatic sutures for open abdominal operations, part of the venous ports used in various types of chemotherapy, etc.

Most patients are satisfied

Despite the results of the research, the sociological data shows that overall, 67% of respondents think that the treatment they received was very good or good.

These results are also supported by the small number of reports of violations that have been filed against oncological treatment. In 2023, a total of 643 complaints about bad medical practices were filed, but only 21 directly related to cancer treatment.

The national ombudsman received 374 medical complaints related to patients’ rights, of which only 16 concerned access and timeliness of oncology treatment.

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

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