National Statistical Institute 

"Health and Justice Statistics" Department

National Statistical Institute
2, P. Volov Str.; 1038 Sofia, Bulgaria

Statistics on healthcare non-expenditure provide information on healthcare human resources, healthcare facilities, and healthcare utilisation.

- The people active in the healthcare sector (doctors, dentists, nurses, etc.) and their status (graduates, practising, migration of doctors and nurses, etc.);

- The available healthcare technical resources and facilities (hospital beds, beds in residential care facilities, medical technology, etc.);

- The health activities or patient contacts undertaken (hospital discharges, surgical procedures, ambulatory care data, etc.).

Annual national and regional data are provided in absolute numbers or as a rate of a relevant population.

Data source are exhaustive annual surveys, conducted by the National Statistical Institute of Bulgaria and the National Centre for Public Health and Analyses at the Ministry of Health, as well as administrative data sources (see section 18.1 ‘Source data’ for more information).

For the collection data on healthcare non-expenditure, the classifications used in the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (https://www.oecd.org/health/health-systems/1841456.pdf ) are applied.

For hospital discharges, the International Shortlist for Hospital Morbidity Tabulation (ISHMT) is used. (https://circabc.europa.eu/ui/group/c1b49c83-24a7-4ff2-951c-621ac0a89fd8/library/6ff71dd5-8200-4fe4-a610-a7707cd47c4d )

For Health Employment, the Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications apply (https://eur-lex.europa.eu/eli/dir/2005/36/2020-04-24 ).

Definitions of mandatory variables are laid down in Commission Regulation (EU) 2022/2294.

Where possible, the statistics are separated by sex (male/female), age group and NUTS2 region.

The Eurostat manual on healthcare non-expenditure statistics provides an overview of the classifications, both for mandatory variables and variables provided on voluntary basis.

National deviations: see Annex at the bottom of the page.

Public health.

The healthcare non-expenditure statistics describe the public health sector from a non-monetary perspective. The statistics explain the number or rate of different healthcare resources, facilities and utilisations. A wide range of indicators are collected from a multitude of sources and therefore, details pertaining to individual variables are given in the Annex.

Definitions of mandatory variables are laid down in Commission Regulation (EU) 2022/2294.

The Eurostat manual on healthcare non-expenditure statistics provides an overview of the classifications, both for mandatory variables and variables provided on voluntary basis.

National changes of statistical concepts and national definitions deviating from Regulation (EU) 2022/2294: see Annex at the bottom of the page.

Registered health professionals or health care facility categories.

(1) all health care staff

(2) all available beds or equipment in hospitals or in nursing and residential care facilities

(3) all discharges or procedures performed in all hospitals

Complete national territory

The availability of the data varies in the different data sets:

Health Employment

Physicians – practising (from 1980 onwards), professionally active (from 2008 onwards), by age and gender (from 2014 onwards), by categories (from 2002 onwards), regional level (from 1993 onwards);

Dentists – practising (from 1980 onwards), professionally active (from 2010 onwards);

Midwives - practising (from 1980 onwards), professionally active (from 2008 onwards);

Practising nurses (from 1985 onwards);

Pharmacists - practising (1980-2000, from 2018 onward), professionally active - (from 2019 onwards);

Practising physiotherapists – from 1995 onwards;

Hospital employment – from 2008 onwards.

Health Graduates

Health Graduates (medical, dentistry, pharmacy, midwifery, nursing) - from 1999 onward.

Physical and Technical Resources

Hospitals - total number (from 1980 onwards), by ownership (from 2004 onwards);

Hospital beds - by function (from 1980 onwards), by sector (from 2004 onwards), regional level (from 1993 onwards);

Beds in residential long-term care facilities - from 2000 onwards;

Medical technology (hospital and ambulatory sector) - MRI units, CT scanners and Gamma cameras (from 2005 onwards), PET scanners, Mammographs and Radiation therapy equipment (from 2011 onwards).

Health Care Activities

Consultations - Doctor consultations (1980-1999, from 2014 onwards); Dentist consultations (from 2014 onwards);

Immunisation rate of people aged 65 and older against influenza –2008 and 2014 EHIS data, from 2019 onwards - annual administrative data;

Breast cancer screening (mammography) and Cervical cancer screening, programme data (2013-2017);

Breast cancer screening (mammography) and Cervical cancer screening, survey data (2008, 2014 and 2019);

Colorectal cancer screening, survey data (2019);

Hospital inpatient discharges and hospital inpatient bed-days, total - from 1980 onwards;

Curative (acute) care (Discharges, Bed-days, ALOS and Occupancy rate) - from 2019 onwards;

Diagnostic exams - CT exams and  MRI exams (from 2011 onwards), PET exams (from 2014 onwards);

Surgical procedures - cataract surgery, tonsillectomy and appendectomy (from 2000 onwards), transluminal coronary angioplasty, coronary artery bypass grafts, cholecystectomy, repair of inguinal hernia, caesarean section, hip replacement, total knee replacement, partial excision of mammary gland and total mastectomy (from 2017 onwards);

Hospital discharge data by diagnostic categories (ISHMT) – from 2005 onwards. The data on inpatient discharges and bed days are broken down by NUTS2 region of a hospital.

Not applicable

The unit is number.

Data refer to the calendar year or 31.12. of the reference year, depending on the data set and Commission Regulation (EU) 2022/2294 requirements.

Regulation on Community statistics on public health and health and safety at work (EC) No 1338/2008 

Commission Regulation (EU) 2022/2294 on statistics on healthcare facilities, healthcare human resources and healthcare utilisation 

Gentlemen’s agreement

National legislation

Law on Statistics

Law on Health

Law on Health Establishments

Ordinance № 1/27.02.2013 of the Minister of Health for the provision of medico-statistical information and information on health establishments medical activities.

Joint Questionnaire on Non-Monetary Health Care Statistics, which is carried by Eurostat, OECD and WHO-Europe.

Regulation (EC) No 223/2009 on European statistics (recital 24 and Article 20(4)) of 11 March 2009 (OJ L 87, p. 164), stipulates the need to establish common principles and guidelines ensuring the confidentiality of data used for the production of European statistics and the access to those confidential data with due account for technical developments and the requirements of users in a democratic society.

Law on Statistics

Individual data are not published in accordance with article 25 of the Law on Statistics. The publishing of individual data can be performed only in accordance with article 26 of the same law.

The date of the statistical information release is shown in the Release Calendar presenting the results of the statistical surveys carried out by the National Statistical Institute. Usually the health establishments and medical personnel data are disseminated 6 months after the end of the reference year.

The calendar is available on the BNSI website: http://www.nsi.bg/en/node/480.

Data on Health establishments and Medical personnel are published on the BNSI website, section Health in accordance with the Calendar presenting the results of the statistical surveys carried out by the National Statistical Institute.

Health care activities data are published on the National Centre for Public Health and Analysis website, section Health statistics.

All data are published in accordance with the Law on Statistics and the European Statistics Code of Practice respecting the professional independence and aimed at objectivity, transparency and equal treatment of all consumers.

Annually.

Annual press release In-patient, Out-patient and Other Health Care Establishments with data on Health establishments and Medical personnel.

Data on HCNE are published annually in the following national publications:

National Statistical Institute

• Health Services
• Statistical yearbook;
• Regions, Districts and Municipalities in Bulgaria.

 National Centre for Public Health and Analysis

• Health Services a brief statistical reference book;
• Hospitalized morbidity in the Republic of Bulgaria.

Health establishments and Medical personnel data are available to all users of the BNSI website under the heading Health - In-patient, out-patient and other health care establishments: https://www.nsi.bg/en/node/3306;

INFOSTAT - Information System for online requests for statistical information: https://infostat.nsi.bg/infostat/pages/module.jsf?x_2=58;

Health care activities data are available of the National Centre for Public Health and Analysis website:  https://ncpha.government.bg/index/3031-godishni-danni.html.

Not applicable.

Data on main non-monetary indicators on health care statistics are provided annually to Eurostat, WHO and OECD via joint annual questionnaire filled-in in strict compliance with the prescribed terms and forms of presentation of the data. From reference year 2021 HCNE data are submitted according to the Commission Regulation (EU) 2022/2294.

At the national level, the data are provided to governmental and non-governmental organizations and other users.

Information service on request can be provide according to the Rules for Dissemination of Statistical Products and Services of the BNSI.

In-patient, out-patient and other health care establishments survey metadata and methodology are available to users on the BNSI website: https://www.nsi.bg/en/content/3308/health-establishments,

https://www.nsi.bg/sites/default/files/files/metadata/Zdr_2_Methodology_EN.pdf.

Not available.

The non-monetary indicators on health care statistics are provided  in strict compliance with the Regulation (EU) 2022/2294 requirements and definitions, instructions described in the Healthcare non-expenditure statistics manual and the Guidelines for completing the Joint questionnaire on non-monetary healthcare statistics.

All surveys conducted by the National Statistical Institute and the National Centre for Public Health and Analysis are carried out at regional level by the Regional Health Inspections (RHI) at the Ministry of Health. The NCPHA and RHI are Bodies of Statistics according to the Law on Statistics. The RHI are responsible for implementation of public health policy in the districts of the country. According to the national legislation applications for establishing or closing down of health establishments are submitted in the RHI in the respective district. This guarantees full coverage and quality of the data in respect to the resources.

At the national level, the coverage is validated with information from registries maintained by the Ministry of Health and the Executive Agency Medical Supervision.

Although identical data are not collected from the surveys conducted by the BNSI and NCPHA, the combined use of the collected information allows data verification and guarantees reliable information of high quality.

The registers maintained by the medical professionals' associations are used as administrative data sources. In accordance with the principles of the European Statistics Code of Practice and the general principles quality management, the registers’ data quality analyses were conducted in respect to the coverage, accessibility, relevance, timeliness, accuracy and reliability.

At the BNSI an integrated quality and security management system has been implemented in accordance with the requirements of BDS EN ISO 9001: 2015 and BDS EN ISO 27001: 2017. The certificate fully meets all international requirements and guarantees the quality of the processes and information security of the entire statistical and information infrastructure of the BNSI, both at national and regional levels.

Data on main non-monetary indicators on health care statistics (health care activities) are provided to Eurostat, World Health Organization (WHO) and Organisation for Economic Co-operation and Development (OECD) via joint annual questionnaire filled-in in strict compliance with the Regulation -(EU) 2022/2294, prescribed terms and forms of presentation of the data.

The data are provided annually to National Centre for Public Health and Analysis, Ministry of Health and its territorial units - Regional Health Inspections, whose functions are to formulate policies in the field of health care at national and regional level.

Data users of health information at national and regional level are the National Assembly of the Republic of Bulgaria, the executive and local authorities, National Health Insurance Fund.

Upon request, data is provided to research institutes, universities, NGOs and other users in conformity with the rules established in BNSI.

Not available.

All 2022 data requirements set out in Regulation (EU) 2022/2294 on statistics on healthcare facilities, healthcare human resources and healthcare utilisation have been met.

1. For 2022 mandatory variables:

 100% - All variables required by the Commission regulation n°2022/2294 are transmitted to the European Commission.

2. For voluntary variables:

70% - Data on medical personnel licensed to practice, foreign-trained doctors and nurses (stock), hospital discharges of non-residents patients (day cases and hospital bed-days), operation theatres in hospital, geriatric day care places and teleconsultations are missing.  ICU beds cannot be broken down into adult and pediatric beds.

The quality of the data depends significantly on the quality of the primary data sources. Most of them are administrative data (e.g. administrative registers) and exhaustive statistical surveys.

Primary data, integrated data, intermediate results and statistical products are regularly assessed and validated.

Not applicable.

Not applicable.

Member States are required to transmit their data to Eurostat in compliance with the Commission Regulation 2022/2294 transmission deadlines.

Member States shall provide the data and reference metadata on an annual basis within 14 months after the end of the reference year.

By way of derogation, data and reference metadata for hospital care and surgical procedures shall be provided within 20 months after the end of the reference year.

All data and reference metadata for the reference year T shall be transmitted to Eurostat by 28 February T+2.

At national level, data are disseminated by T+ 6 months.

BNSI complies with the Commission Regulation 2022/2294 transmission deadlines.

The data are comparable for all territorial regions in the country.

When analyzing the data some specific particularities on medical servicing in Bulgaria has to be taken into consideration. The health establishments are not directly connected to the servicing of population of a given settlement or even of municipality. A great part of health establishments serve the population of a given region or a group of municipalities, and the specialized health care establishments - oncological, dermato-venereological, psychiatric, pulmonary and other service the population of 2 or 3 regions. The establishments under central administration, regardless of their location, serve the population from the whole country.

Data on physicians practicing in health establishments attached to other ministries and medical practitioners working in practices (under a contract with the NHIF) that serve more than one municipality or district are included in the total number but not distributed by municipalities, district and statistical regions.

Health establishments attached to other ministries are included in the total number but not distributed by statistical regions.

On the whole the data are comparable.

See Annex at the bottom of the page for potential breaks in time series for each variable.

Not applicable.

The data from the surveys carried out by BNSI and NCPHA are reconciled.  The data from the statistical surveys are validated at regional level by the Regional Health Inspections and at the national level by the BNSI and the NCPHA.

The data are also validated with information from other administrative sources - the registers of the medical professionals' associations (Register of the Bulgarian Medical Association, Register of the Bulgarian Dental Association, Register of the Bulgarian Association of Health Professionals and Register of Bulgarian Pharmaceutical Association).

The cost and burden are reduced by using data collection, validation and dissemination IT tools.

Revision of published data is possible after validation procedure in accordance with the Regulation (EU) 2022/2294 requirements. In addition, revision is possible due to change in statistical regions (NUTS 2). 

Since 2018, there is a change of the methodology in respect to the counting of practicing physicians and dentists. The changes have been made in aim to avoid double counting and to increase the quality of information.

2010-2017 data for practicing physicians are revised in accordance with the methodological amendments from 2018 as follows:

- medical practitioners working in practices that serve more than one municipality or district are included in the total number but not distributed by municipalities or by district;

- physicians working in specialized practices under a contract with the NHIF are allocated to the specialty they are practiced. Those who practice more than one specialty are included in the total but not allocated by specialty.

Source data for the different variables are given in the Annex at the bottom of the page.

Annual.

Survey data:

-  In-patient, out-patient and other health care establishments – exhaustive annual statistical survey, conducted by the BNSI. The data collection is carried out by the Regional Health Inspections online or through paper documents.

-  Tertiary education (educational-qualification degrees ‘Professional bachelor’, ‘Bachelor’, ‘Master’) - exhaustive survey, conducted by the BNSI via electronic questionnaire Report on tertiary education for Master's, Bachelor's and Professional bachelor's educational - qualification degrees.

-  Special statistical surveys, conducted by the National Centre for Public Health and Analysis - exhaustive surveys via electronic questionnaires Report on Health establishments for hospital, Report on Outpatient health establishments, Report on urgent medical aid centers and Hospitalized cases in health care establishments by type of disease and by age group.

All surveys are included in the National statistical programme.

Administrative data:

-  Register of the Bulgarian Medical Association

-  Register of the Bulgarian Dental Association

-  Register of the Bulgarian Association of Health Professionals

-  Register of Bulgarian Pharmaceutical Association

-  Ministry of Health - information on the recognition of medical training obtained in another country

-  National Health Insurance Fund outpatient cases of cataract surgery and tonsillectomy

The information from administrative sources is requested in an official way in strict compliance with the definitions from Guidelines for completing the Joint questionnaire on non-monetary healthcare statistics. 

Data validation is performed at following stages:

• At data collection – checking coverage and comparing with data for previous cycles. Validation of the scope of health care establishments, both in relation to newly opened, closed and restructured health care establishments during the year, and in relation to normative changes of health care establishments;
• The data from the statistical surveys carried out by BNSI and NCPHA are validated at the regional level by the Regional Health Inspections and at the national level by the BNSI and the NCPHA;
• The data on Cataract surgery-outpatient cases (administrative data source) are validated by cross validation with other data sources - The Hospitals PPP Survey; Case S19, Lens and cataract procedures (Outpatient);
• Before data transmission - checking of separate variables, consistency of table and cross-tabulations.

Imputation is not applied.

Adjustment for non-response and corrections are not applied.

Not applicable.

Methodological Information Annex