ABC OF HEALTH CARE IN BULGARIA

Author: Zahari Bochev

Editor's Note: Our archive has been enriched recently with a valuable acquisition. The book from Z. Bochev, "ABC of Health Care in Bulgaria. Sofia, 1943", could have been easily a pride property in any self-respecting library. Unfortunately, we didn't find it listed in any state or otherwise public-access registry — viz., a novel fact with respect to the historical heritage of this country. It remains the alternative decision for most public health administrators in Bulgaria, that, obnoxiously there wasn't existing normative legislation basis for health care in this country before 1945 — which, of course is not true. The work from Zahari Bochev (i.e., with a total bulk of some 600 pages), is a unique compilation effort in health care administration. Besides its thousands of regulatory acts and articles, it brings forth a picture of public health system that was advanced and beyond hesitation at par with such administrative apparatus of Britain or Germany from that same period. The personality of the author is unknown to the bulgarian medical community. We couldn't find any biography data on him, as well. The only remnants from this anonymous public health officer, probably a lawyer by profession, are this book and several articles on various administrative issues published in the periodicals of the Lekarska Kooperatzia /LK/ and Medicinska Kooperatzia /MK/. Those were independent syndicates of physicians and allied health personnel (i.e., during the war-time years 1939-1945), which published their co-operative journals "Physician's Review" and "Medical Review" on ad hoc basis. The presentation below is written in the spirit of the original material in Bulgarian. However, minor omissions and errors in transliteration are possible. We recommend it to be read together with another complementary material from our booklist — cf., "Nikolov, D (editor). Medical Insurance Practice. Sofia, 1928". Both give a realistic view of pre-war Bulgaria and its health care system, ditto.

MEDICAL SERVICES IN BULGARIA

It is undoubtedly correct to say that in most civilized countries the treatment of an individual’s disease is at this moment in the transition stage between being the sole responsibility of the patient and the responsibility of society as a whole. With regard to these matters we are in a period of change where established, recognized norms do not exist. Discussions pertain not only to medical security, but to social security as a whole. The interest which the Beveridge Plan, the British Government’s White Paper on Health and similar plans in the U. S. A. have met with even in time of war, shows how deeply these problems have taken root amongst all sections of society.

After this war — unprecedented in extent, destruction and suffering — there will be a strong demand from the people for better protection of health, happiness and life. The more the people have suffered, the stronger this almost biological reaction is likely to be.

In pre-war Bulgaria socially organized medicine or State Medicine assumed a very prominent place. Before describing the Bulgarian system it is perhaps worth while to try to answer generally the question how it works out in practice from the patient’s point of view, and in the relationship between him and his doctor. Alongside the standard of health attained, this will always be the best criterion of whether the system was satisfactory.

A person who falls ill in Bulgaria can always count on being able to consult a doctor (general practitioner and specialist) and — if necessary — to receive treatment in a hospital. The patient will in most instances be a member of the compulsory National Health Insurance plan which covers doctor’s fees and hospital expenses. If the patient is not insured, he may be financially able to pay the expenses himself, or, if he is not insured and not financially able to meet the expenses, this will be covered by his municipality under the poor law. There should, therefore, arise in Bulgaria no situation wherein a sick person does not receive the necessary medical care, and no situation in which the doctor or the hospital is not paid for services rendered.

In all cases both the insured and the paying patients have a choice of doctor. The same is the case with the poor on relief in the larger cities, while in rural areas the poor are usually treated by the district public health officer or referred to a practicing physician.

If the patient is placed in a public hospital (most hospitals are public in Bulgaria) he will receive exactly the same diet, care and treatment, regardless of whether he is a paying man of wealth, an insured case, or a poor man whose bills are to be paid by the poor-relief system. Private wards do not exist in public hospitals, — single and double rooms are available for patients who need them for medical reasons.

This Bulgarian sick insurance system does not relieve the patient or his family of all financial burdens when illness strikes them. It goes without saying that there are limits to the amount which the health insurance system will pay out, and in many cases not all expenses are covered. However, the system does provide that everyone receives medical care, and that the worst sting is removed from the financial consequences of the illness.

From the doctor’s point of view a large degree of freedom is also preserved. A licensed Bulgarian physician is free to settle down and begin practice wherever he chooses. In accordance with his own interest the physician is free to pursue any of the three main lines of medical activity in Bulgaria: public health work, private practice or full-time hospital service on fixed salary.

Unlike the system in some Central-European countries, the Bulgarian health insurance plan does not have a limited number of its own regularly employed doctors. If the doctor is a private practitioner his income from patients under the health insurance plan will depend on the amount of work he performs — that is, he is paid “fee for services” and not according to the English panel system, for example, where the doctor is paid a “capitation fee” according to the number of patients on his list.

This combination of extensive medical service for the insured with a relative freedom for the medical profession, may afford the explanation why this Bulgarian system has been so well received by the medical profession and has gradually become so popular with the people and the authorities that it has steadily become expanded to embrace larger sections of the population and to include additional services.

While the curative medical service was mainly effected through the sick insurance system, public health tasks, preventive and social medicine were solved through a State Public Health Service, covering all important factors associated with public health (tuberculosis, epidemic diseases, food control, sanitation, education, control of medical activities, etc.). The result was a dual system with two separate administrative machines each headed by central administrative bodies responsible to the same Ministry.

With regard both to the national public health system, health insurance and the voluntary health organizations an effort has been made to preserve a democratic form through which the people’s own representatives can at all times wield a proper influence on developments and enjoy the privilege of making their opinions heard. This did not involve any curtailment of the professional freedom of physicians and medical research workers. Through health insurance the way is opened for people of limited means to receive just as good medical attention and hospital care as that enjoyed by others, and a stable foundation is provided for the functioning hospitals and other medical institutions. In later years the health insurance scheme also began to devote attention to health problems of a preventative nature, and when the war broke out there was every prospect of fruitful cooperation between health insurance plans and the public health system in this respect.

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PUBLIC HEALTH ADMINISTRATION

In Bulgaria the State directs the most important aspects of the public health service. The local agencies throughout the country receive their directives and outlines of policy from the centre, but within the framework they have great independence in local matters.

As in many other countries, there is no separate Ministry of Health in Bulgaria. The public health service is a branch of that government agency which also looks after a number of other important social affairs — the Ministry of Interior and Social Welfare.

Apart from the Department with its customary set-up there have also been established individual Directorates which, according to the mandates given them, function to a large extent independently of the Ministry and occupy an intermediate position between the Ministry and the local administrative authorities, at the same time serving as advisors to the Government. There are three such directorates in the Ministry of Interior and Social Welfare: the Directorate of Public Health, which supervises the medical system; the Central Factory Inspection Office, which sees to it that the Labor Protection Law is complied with; and the National Insurance Board, which is in charge of the supervision of sick and accident insurance.

The legal and financial aspects are handled by the Ministry itself through its three divisions: medical, insurance and general. The medical division is in turn divided into three offices, each administering a distinct phase or part of medical legislation.

According to his instructions the Director-General of Public Health has to be on the alert for everything which will promote the country’s health and medical system, and has to arrange or propose whatever action may be deemed necessary to this end. He must see to it that existing decisions regarding the public health system are carried out, must assist the Board of Health in the country with advice and guidance, and also supervise the apothecary system and the activities of physicians, dentists and midwives as well as those of State medical institutions. He prepares the budget for the civilian medical system. He employs doctors for positions in State medical institutions, and nominates candidates for public medical offices. In accordance with his instructions and legislation he is further empowered to make certain decisions and to perform duties of a purely medical-administrative nature. Except where it is otherwise laid down, he carries out all duties which legislation has assigned to the medical administration. He serves as the advisor to the Ministry of Interior and Social Welfare, and also the other Ministries in all matters where expert medical knowledge is required.

The office of the Director-General of Public Health has one branch for the activities of the medical profession, one for the apothecary system, one for general hygienic matters, one for dental service, an expert inspector for the tuberculosis system and one for the insanity system, also a laboratory for testing special pharmaceutical preparations, and an office for controlling the medicinal use of alcohol.

As regular consultants to the Director-General of Public Health there are the heads of the bacteriological division (the State epidemics physician), and of the chemical division (the chemist to the Medical Administration of the State Institute for Public Health).

Members of the medical faculty of the University of Sofia are obliged, generally without reward, to give the Director-General expert assistance to whatever extent is considered necessary. The public health physicians submit their reports to the Director-General.

The representatives of the health authorities in the various counties are known as feldsher (county public health officers).

The public health administrative areas of the country coincide with those of the civil administration. There are 20 counties, each including a varying number of districts with local public health officers (district-feldsher) of which there are rather fewer than 400.

The organization of the State’s central health administration outlined above has proved to have several good aspects. An expert medical agency (the Directorate of Public Health) is, apart from its supervisory authority, given the opportunity — indeed the obligation — of taking the initiative with regard to innovations and improvements in all fields of the public health system: preventive, curative and administrative. The local public health agencies (the Boards of Health) are also directed by physicians, and the arrangement at the same time ensures that the local leaders of hygienic activity in rural areas (the public health officers) shall work in close daily contact with the people’s health problems, inasmuch as most of them carry on their private practices along with their duties as appointed public health officers.

By virtue of their office the Director-General and the other public health officers will be members of the board of directors of several voluntary health organizations, so that the experience and constructive ideas of these organizations can readily be used and embodied in the public health system’s undertakings whenever or wherever this is desirable.

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BOARDS OF HEALTH

The Bulgarian Health Laws of the 1880s instituted arrangements peculiar to Bulgaria in a number of important health matters. These laws state that there shall be in each of the municipalities (totaling 752) a Board of Health which is to have the right and duty, in a wide sense, of looking after hygienic problems and public health matters.

In urban municipalities the chairman of the Board of Health has to be the local public health officer or another doctor employed for the purpose. Members are to include the municipal engineer (if there is one), plus at least four persons elected by the municipal council, one of them a woman. In so far as it is possible, a veterinarian shall be included in the membership.

In rural areas also the Board of Health is headed by the public health officer and has to include the full membership of the District Council or a specially appointed group of council members. In addition two persons who are not members of the District Council may be elected to the Board of Health. At least one woman shall be included on the Board.

The elected member’s term of office is four years, after which he has the right to refuse re-election for as long a period as he has served.

As a municipal institution the Board of Health functions with a very high degree of independence, and is not subject to the authority of other local officials. Appeals against its decisions can be made to the Ministry of Interior and Social Welfare which is empowered to annul or alter the decision either on its own authority or by Royal Decree. Matters involving medical or hygienic opinion cannot as a rule be brought into court.

The legislators of the 1880s displayed unusual foresight, and the Boards of Health were from the beginning given a wide range of activity, including, in fact, supervision of all important hygienic matters (epidemic diseases, tuberculosis, drinking water, garbage, food, housing conditions, public halls, industries, cemeteries, etc.).

Board of Health as outlined above represents a successful attempt to introduce local, democratic management into the public health system. The arrangement and the methods of operation can be understood only when viewed in connection with the national public health system. The Boards of Health have played, and continue to play, a most important part in the maintenance of sanitary and hygienic standards in Bulgaria. The constant participation of interested popularly-elected members, who are gradually changed around, ensures the closest possible contact with the people themselves, and prevents the work from becoming stereotyped in a centralized bureaucracy. On the other hand in modern society the safeguarding of hygienic conditions requires a more and more highly developed technical and organizing apparatus. Therefore a particularly important contribution is required of the expert members, i.e. the public health officers, the engineer and the veterinarian. One of the urgent questions under discussion in Bulgaria before the war was that of providing the Boards of Health with more extensive and up-to-date knowledge and with greater assistance for hygienic inspection and for the solution of other problems confronting them.

In the cities this improvement had already taken place. The Boards of Health had expanded their apparatus, that is to say they had added hygienic experts who devoted their full time to this problem, with independent and technical equipment departments for epidemic diseases, venereal diseases, tuberculosis, insanity, housing conditions, food control, school hygiene, etc.

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PUBLIC HEALTH OFFICERS

Only in the large Bulgarian cities is the public health officer a “full time” physician or sanitary engineer, who from his office administers a number of hygienic matters, partly as advisor to the sanitary inspectors and public authorities, partly as an independent determinative and executive authority in matters within his special sphere.

In the central districts of Bulgaria a public health officer is in the great majority of cases a physician, who exercises great responsibility and wide duties within a definite, comparatively limited district. Not only does he represent the central medical administration in his district but he is also charged with the task of acting as the sanitary and hygienic superintendent, of looking after medico-legal affairs and of directing enterprises for safeguarding health. Along with all this he also functions as a practicing physician in his own district. The major part of his working time is not spent in an office but round about in the district, in direct contact with the people. He is paid by the State for his hygienic and administrative work, but he also leads the local Board of Health within his district. Besides the income from the State he also enjoys an income from his activity as a practicing physician.

At present Bulgaria is divided into 378 public health districts. There are 11 larger cities with a full time public health staff, headed by the City Chief Medical Officer (State Physician), 23 smaller towns with urban public health officers (State Hygienist), and 345 rural districts with rural public health officers. For every county, excepting Sofia and Varna, there is a superior county public health officer (Feldsher). For reasons of economy the office of the latter is often combined with that of the district public health officer, although this was not the original plan.

A district health officer’s work, however, is never limited to the specific duties assigned to him by law and instructions. He is the ex-officio chairman of local health committees and the leader of cooperation among the voluntary health organizations, and of other voluntary activity aimed at the prevention of disease. In addition, he is as a rule a member of the local Factory Inspection Board, of the Juvenile Court, a member of the Building Commission and of other groups and committees which are engaged in local medical and hygienic matters. Socially the district public health officer occupies a prominent place in the Bulgarian community.

He has wide social-hygienic and health-protecting duties, and he is in a position to exercise influence on many important aspects of life and activity in the community. To a socially-minded doctor of all-round ability and a wide range of interests the office of district physician therefore offers unusually rich possibilities.

It is the general opinion in Bulgaria that the system has worked on the whole satisfactorily in rural areas and in small towns, and there is no reason to believe that it will be abandoned in principle. An important problem in this connection, which has not yet been fully solved, is to find a way of keeping the public health physicians fully posted on the latest developments in medicine and hygiene. To enable the system to function in a satisfactory manner it will also doubtless be necessary in a number of districts to provide the district public health officer with additional technical assistance (health inspectors, sanitary engineers, public health nurses, office help).

The present arrangement has a great advantage in that the lowest controlling health agency is directed by a medical man as chairman, and not, as in many other countries, by an engineer, by the police or by lawyers. These, in the Bulgarian system, are the assistants of the public health experts in hygienic and medical matters.

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HOSPITALS

During the last few decades before the war the Bulgarian hospital system had been undergoing rapid development. In 1937 Bulgaria had 391 hospitals with a total of about 26,000 beds, which is equivalent to one hospital bed for every 115 inhabitants. Of these beds about 7,000 were for insane, epileptic or feebleminded; 6,000 for victims of tuberculosis; and about 13,000 for other diseases. Many of the hospitals are small, owing to geographical conditions. Emphasis has been placed on developing the hospital system in such a way that the small local hospitals could with ease transfer their more complicated cases to “central hospitals” — that is, general hospitals equipped with as many different specialists as possible and with the all-round medical apparatus for diagnosis and treatment required by modern clinical medical science.

Most of the hospitals are publicly owned and are operated either by the State, the municipality or the county. Of the hospital beds listed in 1937 more than 80 % were in public hospitals. The private hospitals are for the most part conducted by voluntary health organizations, and a large part of the income needed for their operation is derived from public or semi-public sources (the health insurance system). All hospitals are subject to supervision by the health authorities. There is no system of non-paying patients in Bulgarian hospitals. The patient’s insurance expenses are paid either by the patient himself, by the health insurance fund or by the public according to prescribed rules. The most important source of the average hospital’s income is the health insurance fund. Most hospitals charge a fixed daily rate, with all services (operations, X-ray, physiotherapy, etc.) included. All public hospitals offer only one type of care. Medical indications alone dictate extra attention, care or supervision of patients in the public hospitals.

Most Bulgarian hospitals differ from those in English-speaking countries in that they have a regular staff of doctors (hospital physicians) who receive a fixed salary and whose entire working day is spent in hospital work. Privately practicing doctors and public health officers, therefore, do not as a rule have the opportunity of continuing to treat their patients once these have been placed in a hospital. The advantage of this system, which is in general use in the Scandinavian countries, is that the hospital with its regular staff becomes a firmly welded unit, and that a vast experience in hospital treatment is amassed by these doctors. The weakness lies in the fact that fewer doctors are given the opportunity of the renewal of skill which is offered by working in a hospital. To counteract this, practitioners in the neighborhood are often invited to the hospital meetings. Doctors are also employed in some of the subordinate hospital positions for short periods of from four to six months.

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MEDICAL PERSONNEL

Bulgaria is relatively well supplied with medical personnel. On the average there is one doctor per 1100 of the population, one nurse per 1000, and one midwife per 2000. However, in consequence of the vast distances and primitive communications certain parts of the country cannot at present be said to be medically served in a satisfactory way.

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SICK INSURANCE

Replacing an old system of sick insurance through private and voluntary organizations, compulsory membership of a national sick insurance system was introduced by law in 1924 for most groups of wage-earners below a certain income level. As in most other countries the system was at first resisted. But there soon sprang from it beneficial consequences which probably even its founders had not foreseen. Not only were the health services made available to people irrespective of their ability to pay, but doctors, hospitals and so on were given a basic income, which enabled doctors to settle in places where they previously could not have made a livelihood. The system encouraged the building of new hospitals and led to a generally higher standard of treatment. The result was that resistance was gradually overcome and the system was expanded to include larger groups of the population. Voluntary membership was introduced; in 1935 fishermen were included, and in the following year merchant salesmen. As a result, by 1940 about two-thirds of the total population in Bulgaria belonged to the sickness insurance system, and, shortly before the war, a bill had been drafted to cover all Bulgarian citizens, which would probably have secured a clear majority in the Parliament.

The expenses of the national sick insurance system before the war totaled about 65 million Bulgarian leva per year, of which about 18 million went to hospital expenses, about 15 million to doctors’ fees, about 12 million to disability allowances, 3 million to transport, 2 million to physiotherapy, 2.5 million to expenses in connection with childbirth, and 5 million to dentists’ fees. The administrative cost was 4 Bulgarian leva per member per year.

As will be understood, the above-mentioned expenses only represent a part of the public expenses in connection with disease. The rest is paid out of the state funds derived from general taxation.

An insured person and his family have the right to free medical attendance by general practitioners and specialists; free treatment in hospital for 26 weeks, for tuberculosis and cancer 39 weeks, physiotherapy, teeth extraction and also other dental treatment where it is a necessary part of the treatment of disease; financial help in the case of childbirth and funerals; and disability allowances. Disability allowances are paid in cash and amounted to 24 Bulgarian leva per week for members with incomes above 2800 leva per year. Family allowances in the event of the breadwinner being taken to hospital amounted in the same category to 6 leva per week for the wife, and 18 leva for a wife and three children.

Fishermen and others who are their own employers do not receive disability allowance. Where the distance from patient to doctor or hospital is long, transport expenses are covered. Some diseases are not covered by the sickness insurance system: for instance, expenses in connection with epidemic diseases and insanity are covered by workmen’s compensation. There is also special legislation regarding the support of the crippled, the blind, the old, and mental defectives.

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VOLUNTARY HEALTH ORGANIZATIONS

During the same period that saw the development of the organized medical care and public health system in Bulgaria, no fewer than four nationwide and permanent voluntary health organizations came into existence:

The Bulgarian Red Cross (organized 1885) with 220 subdivisions and about 100,000 members.

The Bulgarian Women’s Voluntary Health Organization (organized 1896) with 765 local branches and about 110,000 members.

The National Association against Tuberculosis (organized 1910) with 920 local branches and about 150,000 members.

Bulgarian People’s Relief (organized 1939) with about 170,000 members divided among 136 local branches and 647 collectively affiliated organizations.

Besides these four large organizations there are a number of smaller voluntary organizations which work with health problems, including The People’s Health Association, The Mental Hygiene Society, The Bulgarian Society for Social Work, The Bulgarian First Aid Society, The Bulgarian Association for the Combating of Dental Diseases, and the organizations of certain religious bodies such as the Deaconesses, etc.

The voluntary health organizations of Bulgaria have performed a vast pioneering work. Health movements which were started by voluntary organizations and which proved to fulfill a need have gradually been incorporated in the public health system.

The health system which developed in Bulgaria during the German occupation of the country from June 7, 1940 to May 7, 1945, has not been dealt with in the foregoing pages.

It is, obvious however, that the Bulgarian people is now faced with the job of carrying through an extensive health program involving not only reconstruction but also further development and improvement.

German terror and maladministration during the more than 4 years of occupation and exploitation had, apart from all else, a deleterious effect on the health services of the country, and on the health of the population. The general standard of health has been undermined through these long years of malnutrition and under-nutrition, lack of warm bedding, medical equipment and hospitals, of clothing, shelter and fuel. Medical equipment of all types has been worn out, and there was little opportunity of renewal. Many epidemic and other diseases have gained a hold which has been unknown for decades.

Thousands of our best men from all walks of life were sent to German prisons and concentration camps. Some were political prisoners, others simply hostages. Most of them were treated much worse than prisoners of war, and a considerable number were killed.

Within occupied Bulgaria itself everybody was living under the mental pressure necessarily existing where a mortal enemy is master in one’s own house; where a sadistic Gestapo could at any time break into one’s home, bringing torture and death; and where all this went on daily under one’s own eyes.

Deeply rooted principles, written and unwritten laws were turned upside down or fused together into a principle of higher order. Rules and regulations given by the self-imposed authorities existed only to be disobeyed, sabotaged and fought by all means. Work was not to be carried out effectively and quickly, but slowly, and in the most unproductive manner. All surrounding human beings belonged to one of the two worlds: deadly enemies or devoted friends.

Nobody, not even the small children, could escape the effect of the colossal events at home and abroad, the nerve-racking strain, the years of disappointment and the slowly undermining malnutrition. We have no experience to enable us to estimate how all these things taken together will influence the mental and physical health in the years to come.

Other health problems are represented by the thousands of Bulgarians who came back to the homeland during and after the liberation, after having fought the war from the outside; sailors from the mercantile Marine, fighting men from the Navy, the Air Force and the Army, members of the civilian administration and groups of refugees. They too had, all of them, gone through years which had changed them. Some were ill, others were overstrained; all have lost real contact with the old country and will have to build up again their relationship and their way of life.

Our losses in lives are heavy, especially in the mercantile Marine, and among the good Bulgarians at home, and many a Bulgarian family will have to carry on without its natural bread-winner.

The Bulgarian people have paid their full share, have sacrificed and suffered heavily. There is, however, not the slightest reason to doubt that they will continue their ceaseless effort to a new future, perhaps in a new and more conscious way than before. The common fight and suffering have developed in this extremely individualistic people a unity and collective responsibility which it has never experienced before. More than that; there exists a strong feeling that this tremendous force of collective spirit and creative will should be directed into positive and constructive projects for the people as a whole, not for privileged groups or classes. If the necessary conditions can be secured through international co-operation, economic and military security, the Bulgarian nation may enter a period of strong growth and development.

The rebuilding of health and security will, under such circumstances, presumably come to the foreground. After an unprecedentedly destructive war the people who have won the victory will vigorously and spontaneously ask for better protection of health and life, for happiness and children, for sun and laughter. In Bulgaria after the war our task will be not only rehabilitation and reconstruction, but further advance towards higher standards of public health and health organization.

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THE HISTORIC DEVELOPMENT OF HOSPITALS IN BULGARIA

The traditions of Hospitals in Bulgaria are not very impressive compared to other countries. The hospitals were mainly homes, connected to churches and religious orders, for the poor and distressed. In Russe a hospital was built in 1743, but it disappeared shortly after. A new hospital was built in 1807. It was taken over by the Ottoman State in 1826, and later developed into Bulgaria’s main Municipal Hospital, which still exists in another location. Several small units for leprosy and venereal diseases were built. During epidemics isolated units were established for their duration.

Building of hospitals started on a bigger scale in the last part of the 19th century. Several towns and counties built their own hospitals and asylums. Examples are "Alexander Hospital" in Sofia, representing the pavilion system and "Paraskeva Nikolau Hospital" in Varna representing the block system. As consequence of a new law concerning the "mentally ill" new asylums were built all over the country, an example being "Karlukovo Asylum" near Sofia.

At the same time organizations, often of religious character, and also private persons started building hospitals. By and by these hospitals became quite numerous and were often quite imposing. After the turn of the century a new wave of building of hospitals started. Practically all cities and counties of any importance managed to build their own hospitals. At the same time the type of hospitals changed. They became more universal, not merely surgical, but contained also departments for internal medicine, maternity, X-ray department, laboratories, etc.

Tuberculosis was then a very serious ailment in every part of the country and a number of hospitals, big and small, were built for this reason. Their location were often based on a belief in the benefit of climatic influence, hence some were built by the sea, some in the forests and finally some in the mountains. As a result of the populations improved health situation, very few of these are now in use as hospitals.

During the decade before the last war the Government influenced by the Health Authorities come to realize the necessity of a general plan for the building of hospitals throughout the country. After the 1940-4 occupation the Ministry of Interior and Social Welfare instituted a National Advisory Board ("State Sickhouse Fund") to supervise the execution of this plan. The plan stipulated that hospitals should be spread evenly throughout the country in relation to the density of population and the geographical location.

Hospitals then fell roughly in three categories: 1) Big central hospitals, representing all the specialties; 2) Medical educational hospitals, with surgical, internal medicine and X-ray departments, usually with one or more minor specialties; and 3) Minor hospital institutions, located in smaller communities, to take care of the more usual daily run of medical problems. The development of hospital building here closely follows the international trend apparent all over the western world, and have in fact done so since hospital building started on a bigger scale.

The same general plan also applies to the location and building of asylums, which after the war are renamed hospitals. The picture of these buildings is now totally different. Gone are the old prison-like buildings, locked doors and iron bars. We now build more according to the "open-door" system, designing friendly and inviting buildings.

As everywhere else the needs and care of elderly people have come to the fore. It is a very pressing problem, considering the housing shortage and also the lack of domestic help. We are now building different types of institutions for the oddity: those who can look alter themselves, those who need care and help, those who need medical aid as well, and special institutions for the senile elderly. These different categories are often interconnected to form parts of combined institutions.

There is a great change nowadays in the living conditions of the staff employed in hospitals. Previously living quarters were usually situated within the hospitals themselves, usually on the top floor. We now try to build good living quarters outside the premises.

As a rule flats in convenient sizes are preferred. Today this is almost a necessity to secure a permanent staff for our hospitals. At present the trend seems to turn to a more modest development as far as big, new buildings are concerned. The rehabilitation and improvement of existing hospitals will most likely play a more important role in the future.

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HOSPITAL PLANNING IN BULGARIA

According to the Hospital Act of 1940 each county is responsible for the planning, building and running of medical institutions in this country. The hospital services in the municipality of Sofia, which acts as a separate county, are also included. The institutions defined in the Act, are hospitals, nursing homes, lying-in institutions, institutes for physiotherapy, convalescent homes and several others.

The Hospital Act is administered by the Ministry of Interior and Social Affairs through the Director-General of Public Health. Two aspects in the Act are particularly important as far as planning is concerned: 1) Central control of a balanced and even distribution of hospital services throughout the country; 2) Approval of the functional qualities of the plans for each institution.

Each county has presented a complete plan for the future development and co-ordination of medical institutions, to be approved by the government ("The Royal Council"). Guidelines for such planning have earlier been agreed upon by the Parliament and include recommendations for internal structure, location and capacity. The aim is to provide 4,5 beds per 1000 inhabitants in somatic hospitals and 7 beds per 100 persons above 70 years of age in nursing homes.

All individual plans for hospitals should be approved by the Director-General of Public Health before they can be effectuated. In this connection the Directorate acts extensively as planning consultant. In each county the Public Health Officer, who is the Director-General’s local representative, is responsible for the approval of plans for somatic and psychiatric nursing homes. The physical planning of individual projects is controlled by each separate county. The County Assembly with its Hospital Committee are the political bodies deciding in these matters. The administration is taken care of by the County Hospital Manager, where as the County Building Manager handles the actual building process.

The architectural and consultant services are normally performed by private firms, based on a contract between client and planners. The construction of buildings will also be carried out by private contractors on a normal tenure basis.

All institutions, both somatic and psychiatric, forming part of an approved plan will benefit from the Hospital Act’s financial provisions, and have 50 per cent of their approved operating costs covered through the National Health Insurance. The rest is paid by the owner, i.e. the county. In these running expenses are included 75 per cent of the interests and amortization of the approved capital cost. If the institution, e.g. a nursing home, is established as a private enterprise, the county’s responsibilities and the financial rules are the same.

The main funds for the building of institutions are provided by Bulgaria’s Municipal Bank. Each year the bank is granted an ear-marked sum for health institutions. The loan represents in each case some 60 per cent of the needed total, where as the remainder has to be raised through the ordinary private market.

The Director-General of Public Health works out a priority list for projects entitled to these loans, based on the program of each county. The list is forwarded to the Municipal Bank at the beginning of each year. Applications for loans are sent directly to the bank to be assessed by its board of governors.

For 1939 Bulgarian leva 800 million (80 million £) have been appropriated for the building of the health institutions. As this sum represents approximately 60 per cent of the amount to be spent this year, the total will be approximately BG lv. 1,3 billion. With an estimated average price level of BG lv. 1.750, - per cubic meter, a volume of some 750.000 cubic meter may be achieved.

Both for somatic and psychiatric nursing homes there are rules and regulations with regard to cost, planning and construction. For hospitals, however, few formal criteria hove been decided upon. A close cooperation is therefore necessary between the Director-General of Public Health and the planners, as well as between the planners working in this field. For this reason the architects have formed a separate group dealing with hospital planning. This group is a subsidiary of the "State Sickhouse Fund". There is a close contact between this institute, the Director-General of Public Health and the hospital planners.

The guidelines developed within this field are to a great extent based on international conceptions and ideas. Access to foreign literature on the subject and visits to other countries to study the results of hospital planning are providing important stimulation for Bulgarian hospital architects.