From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Bulgaria’s response to the coronavirus pandemic – the August update (2020)

 

On May 13, following two-months of lockdown, the Bulgarian government amended the Health Act and replaced the state of emergency with a state of emergency epidemic situation which allowed the Minister of Health to implement a wide range of anti-epidemic measures in case they were needed. After a period of steady decline in newly confirmed COVID-19 cases, during the second half of May 2020, some restrictions were gradually lifted. This included reopening of hotels, fitness centres, gyms and big shopping centres, kindergartens and nurseries. Indoor sports activities, cultural and entertainment events, as well as conferences, congresses and exhibitions were restored with a limited number of spectators, attendees and visitors allowed.

In the first half of June, indoor visits to restaurants, cafés and entertainment facilities, followed by discotheques and nightclubs were allowed; however, restrictions were imposed on the number of attendees. The compulsory wearing of face coverings in indoor public places (except for passengers in public transport, patients in healthcare establishments and customers in pharmacies) was eased to being recommendable on June 15, but a week later it became compulsory again due to increase in new COVID-19 cases.

With the easing of restrictive measures, a reverse trend in the spread of the epidemic has been observed. Due to the significant increase in newly recorded cases in the second week of June, the government extended the state of emergency epidemic situation until August 31 and some transition measures were amended. From July 10, indoor and outdoor sports events were to be held without an audience and additional restrictions on the number of visitors to indoor venues such as discotheques and night clubs were implemented. Closure of external borders and the mandatory quarantine of passengers arriving in Bulgaria were gradually eased throughout June, aiming to support tourism. As of July 15, citizens of EU member states (except Sweden and Portugal), Schengen Agreement countries and 13 non-European countries were allowed to enter Bulgaria without any restrictions. In addition, passengers from several other countries may enter Bulgaria upon a negative PCR-test.

Additional efforts to expand testing capacity have been made since May. Currently, 38 laboratories are certified to perform RT-PCR diagnostics, and thus the number of daily performed tests has significantly increased. However, there is still criticism that Bulgaria lags behind many European and neighbouring countries regarding the number of performed PCR tests per one million population.

New measures for supporting different sectors and enterprises affected by the pandemic and particularly agriculture and tourism have been adopted. These included allocation of EU development funds, wage subsidies, amendments to the Value Added Tax Act, and some social programmes for vulnerable groups. At the end of July, the government announced a EUR 56.3 million package of social and economic support, financed by the state budget to help vulnerable groups, provide compensations for the unemployed, and monthly supplements to pensions as well as financial incentives for medical specialists and other professionals. In addition, the Ministry of Economy will spend EUR 1.2 billion under various programmes aiming to alleviate the negative consequences of the pandemic on different businesses and to support economic recovery.

 

Reflection

The relaxation of restrictive measures relieved the pressure on the economy and the social system but has led to a considerable increase in registered COVID-19 cases and put tension on the health system. Initially, lockdowns and other restrictions were successful in containing the spread of the pandemic; however, currently some recommended measures – e.g. physical distancing and the wearing of face coverings – are not being strictly followed. Public awareness of transmission mechanisms and protective measures is relatively high, but many Bulgarians underestimate the risk of transmission and believe that the virus is not that dangerous. Currently, the anti-government protests and political unrest in Bulgaria compromise further the rules for keeping physical distancing and avoiding mass gatherings. Moreover, after the easing of restrictions, testing and tracing regimens have not succeeded to suppress local outbreaks.

Despite the steep increase in COVID-19 cases in the last two months, the government has not announced plans to impose stricter restrictions again. According to the health authorities, the health system can manage the current pressure of increased number of cases requiring hospitalisation. The rapid early response allowed the health system to prepare for the pandemic; however, the healthcare workforce capacity raises particular concerns.

Despite initiating different measures to attenuate the short-term economic losses and protect vulnerable groups, their relevance and sufficiency have continuously been debated. The Bulgarian economy relies heavily on tourism, which has already been seriously affected by the pandemic. The second peak of COVID-19 cases in recent months (June and July) could amplify the negative consequences on the tourism sector, and thus deepen the economic recession and hamper recovery.

Bulgaria’s response to the coronavirus pandemic – Update (May 2020)

Rositsa Koleva-Kolarova*¹, Antoniya Dimova*², Mariya Rohova*²

¹ Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom. rositsa.koleva-kolarova@ndph.ox.ac.uk

² Health Economics and Management Department, Faculty of Public Health, Medical University – Varna, Varna, Bulgaria

 

Additional measures to contain the pandemic and expand diagnostic and treatment capacity were implemented in April. These included mandatory face masks in public, closing of farmers’ markets, further restrictions on travelling within the country, and lockdowns of the capital Sofia during Easter holidays and settlements and neighbourhoods with high infection rates.

Current testing capacity includes 24 laboratories with 52,931 PCR tests performed (7,500 tests/million). At the time of writing (8 May), 355 patients (a quarter of all active COVID cases) were being treated in hospitals, including 43 in ICUs, which is still far below the capacity of 7,473 inpatient COVID beds. COVID wards were prepared in every public hospital except in specialist oncology hospitals, and in many private inpatient facilities.

A particular focus has been put on capacity losses due to infected health workers (201 or around 11% of all COVID-19 cases). The number of newly infected medical workers have raised concerns, particularly in some district hospitals, which ran out of personnel.

Transition measures include re-establishing suspended maternal and child consultations, vaccinations, and planned hospital admissions as of April 21. Specialised outpatient services and hospitals have gradually restarted planned admissions prioritising urgent cases. Transplantation services and visitors to all healthcare establishments are still prohibited.

On April 27, city parks and gardens were initially opened to families with children and for sports. Several days later, visits to mountains and parks outside cities were allowed in strict compliance with requirements for physical distancing, and designated checkpoints for entry and exit.

On May 1, wearing of face masks outdoors was lifted but face masks remain mandatory in closed public spaces (e.g., stores and public transport).

In early May, the government announced plans to gradually lift some restrictions and re-open driving license training centres, outdoor individual sports and swimming pools, outdoor gardens of restaurants and cafes, and remove entry and exit checkpoints in district cities.

Schools will not reopen for the current academic year and students will continue distance learning.

The government declared that the state of emergency will not be extended beyond May 13.

Economic and social support measures include revisions of the 2020 State Budget Act with a set deficit of 2.9% of target GDP and a raise of the national debt ceiling, introduction of special financial package to support different enterprises, interest-free or collateral-free loans for employees on unpaid leave, self-employed, micro, small and medium-sized enterprises, and social support for vulnerable groups, including delivery of free food and patronage services for elderly and disabled. 76.7 million euros were set aside for capital investments in innovative companies with a potential to stimulate economic recovery after the crisis. An additional 10.22 million euros were set aside for parents on unpaid leave caring for their children. Supermarkets were obliged to supply Bulgarian farmers’ products. 

Reflection on COVID-19 response in Bulgaria

Bulgaria has one of the lowest transmission rates in Europe and the capacity of the health system is still far above the needs. Most of the newly diagnosed patients were registered in particular places and settings (clusters), while the spread of the virus among the general population is known to be low. However, the increasing numbers of infected medical professionals, inhabitants and staff in care homes, and people living in some suburbs, raise concerns. Availability of PPE for medical professionals throughout the country and mass testing hsd been constantly debated.

Public opinion regarding anti-epidemic, economic and social support measures is divided. The government and the National COVID Task Force have been continuously criticised that proposed measures did not rightfully reflect the state of the pandemic in the country: some claim that unnecessarily strict measures were imposed, while others criticise relaxing of the anti-epidemic measures at the time when the number of newly diagnosed COVID-19 patients is still increasing (as of 8 May, there are 1,865 COVID-19 cases and 84 deaths).

The lockdown is expected to have a significant impact on the economy. Some economic measures, especially targeting restaurants and hotels, are seen as partial and therefore with no significant impact on business.

Bulgaria’s response to the coronavirus pandemic – Original post (April 2020)

Rositsa Koleva-Kolarova*¹, Antoniya Dimova*², Maria Rohova*²

* all authors contributed equally to this report

¹ Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
² Health Economics and Management Department, Faculty of Public Health, Medical University – Varna, Varna, Bulgaria

The first four cases of the SARS-Cov2 in Bulgaria were announced on 8 March 2020. Ever since, this number has increased gradually and at present, on 5 April, there are 531 confirmed cases and 20 deaths. The government started implementing a series of measures early on aiming to contain the wide spread of the pandemic. These measures were proposed by the National Covid Task Force (NCTF, called National Operational Headquarters) established on 27 February, and introduced by orders issued by the Prime Minister (PM). On 13 March, the parliament declared a state of emergency for a period of one month, and on 3 April extended it to 13 May.

A national phoneline for Covid19 inquiries and consultations with epidemiologists was launched in February. The budget of the Ministry of Health (MH) was supplemented with additional funds for supporting prophylactic and anti-epidemic measures. The National Medical Expert Council was established to prepare algorithms and guidelines for diagnosis and treatment.

Preventive measures, triage and testing

Early preventive measures in February included testing and quarantine of symptomatic passengers, and surveillance of asymptomatic passengers coming from pandemic regions and countries. After diagnosing the first 4 Covid19 cases, self-isolation for 14 days of passengers from pandemic countries and contacts of confirmed cases became compulsory. All hospitals with confirmed cases were quarantined for 14 days and visits to all healthcare establishments were prohibited.

Public gatherings restrictions escalated from suspending indoor sports, children’s and cultural events, and prohibiting audiences at outdoor sports events on 8 March to suspending all public gatherings on 13 March, and banning gatherings of more than 2 people in public on 17 March. Social distancing recommendations included physical distance of 1m in public places and at least 1-1.5m indoors.

On 13 March childcare facilities, schools, universities, shopping centres, food and drink, sports and entertainment businesses were closed, and working from home wherever possible was recommended. Public services, bank/insurance offices, supermarkets and pharmacies remain open ensuring space for physical distance between customers. On 21 March the closures were extended to parks, sports grounds and playgrounds.

In the period 18-26 March, Bulgaria effectively closed its borders to foreigners allowing only Bulgarian citizens in and travelling within the country was permitted for work and health reasons only. Violation of measures is penalised by high fines (from €2,556 to €7,700).

Economic relief measures include extending payment periods for household bills and deadline for submission of tax declarations. Banks are not allowed to freeze bank account of citizens and hospitals, or impose penalty interest rates. Employers are paid compensations to retain workforce and cannot place employees on unpaid leave without their consent.

Guidelines for medical specialists and institutions were issued in February. Triage, treatment and hospitalisation guidelines are in place since 16-17 March. The first point of contact for suspected Covid19 cases are their GPs, or the regional health inspections (RHI) for people without a GP which provide consultations and medical surveillance during the home treatment and quarantine period for mild cases. RHIs maintain lists of all individuals under quarantine in every district of the country. Home treatment and quarantine for 28 days is mandatory for asymptomatic and mild cases. Confirmed Covid19 patients over 60 years of age are compulsory hospitalised as well as patients with immunosuppressed conditions, comorbidities, respiratory exacerbations, and any patients who cannot be quarantined at their homes. The quarantine period after hospital discharge is 28 days.

Testing for SARS-Cov2 started in February for specific population groups, including symptomatic passengers coming from China, Taiwan, Sri Lanka, and patients admitted to the hospital wards for infectious diseases. Initially the number of performed tests was small but gradually the testing capacity was increased to an average of 300 tests per day. At present there are a total of 15,899 tests performed.

Treatment capacity
Maternity and child consultations, prophylactic check-ups, vaccinations, and planned hospital admissions were suspendedThe MH issued a list of hospitals dedicated (but not exclusively) to treating Covid19 patients (2,063 ICU beds equipped with 1,463 ventilators). Additional ventilators would be ordered and personal protective equipment (PPE) has been received. Currently inpatient capacity is considered sufficient. Testing capacity has been increased by involving more laboratories. The export of quinine-containing drugs, PPE and disinfectants was prohibited.

Workforce
Bulgaria has a major shortage of medical staff (6.6 nurses and 4.2 physicians per 1,000 people in 2018). It is common that retired physicians, nurses and other medical staff still work in health services. NCTF has called for and recruited volunteers among medical students and retirees.

Reflection on COVID-19 response in Bulgaria
Although the number of cases and deaths are rising, Bulgaria is still lagging behind the exponential geometrical growth which other countries in Europe are facing. There are claims that this is attributable to the rapid early response and the introduction of much more strict measures as compared to other European countries.

There is ongoing public dispute and the media is sparking discussions that measures in Bulgaria, e.g. declaring state of emergency, lockdown of people and businesses, and imposing high penalties (perhaps the highest in the EU) for breaching the preventive measures, are restricting the human and democratic rights of Bulgarians.

Medical professionals have expressed concerns that morbidity and mortality from other diseases may increase as a result of suspension of planned hospital admissions, and the government has announced plans to resume planned care. There are also concerns that strict lockdown measures will negatively impact the mental health of people not allowed to go out for solitary walk or exercise.

Currently, the rapid early response and lockdown seem to have contained the early spread of the disease. The challenge remaining, though, is that people are still susceptible in the absence of vaccine and the fear is that once strict measures are removed the number of Covid19 cases will start rising again.

The NCTF have been quite realistic that the spread of Covid19 is very likely underestimated with the chairman citing 2 out of 11 actual cases being identified. There is also awareness that the number of performed tests might be contributing to the underestimation and there are continuous efforts to increase testing capacity.

Preventive measures have come at significant costs for the self-employed and small size businesses in Bulgaria, and the economy. There are concerns over the growing unemployment rate and the pressure that will put on social system. There are also debates on whether economic relief measures are sufficient.

Although it is too early for lessons learned, it should be noted that while stepwise introduction of measures might not be sufficient for pandemic containment, rapid early introduction of strict measures might contain the exponential growth of cases. The Bulgarian health system is ranked 31 out of 35 in Europe according to the Health Consumer Powerhouse in 2018; however, early rapid response has allowed this system to currently manage Covid19 cases requiring hospitalisation without having to make the choice of which patient to treat and which not. It is not certain whether similar containment could be achieved with less strict measures. At present it is not certain either how and when the lockdown exit will be implemented while containing the Covid19 spread.

References:
Information published on the websites of the Ministry of Health in Bulgaria (http://www.mh.government.bg/bg/novini/aktualno/) and Radio Free Europe for Bulgaria (https://www.svobodnaevropa.bg/) has been used to write this report.

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