Problem: Ageing population, with nearly a fifth over age 65 in 2011; high and rising prevalence of chronic disease, comorbidities and disabilities; scope of services too narrow to adequately manage the full range of health and social care needs; expensive institutional and specialized services overused.
Solution highlights: The introduction of home care services was proposed as a patient-oriented solution for ensuring appropriate service provision closer to home; a pilot approach allowed the gradual rollout and testing of an existing home care model being implemented abroad, which was adapted to meet the Bulgarian context; efforts to introduce home care included creating new roles and responsibilities for the health workforce and developing information and communication resources; establishing the necessary health system conditions, including the development of a supportive legal framework, is an important area of focus for advancing the sustainability and scale of the current transformations.
Description of practice
Bulgaria is faced with an ageing population, with nearly a fifth over the age of 65 years in 2011. A parallel rise in chronic disease, comorbidities and disabilities can also be observed. In this context, the existing health system has faced difficulties in providing care to an increasingly complex patient population. Unmet care needs became increasingly evident within the elderly population, partly as a result of the narrow scope of services available, the exclusion of supportive social services and the lack of easily accessible care options for this group.
This initiative sought to introduce the concept of home care services to the Bulgarian health system. Working in partnership with the Swiss Red Cross and the nonprofit home care organization Spitex, the Bulgarian Red Cross designed and adapted international home care models for application in Bulgaria. In 2003, the first Bulgarian home care centre was launched and began offering services to the local elderly population; 11 additional centres have since been opened to provide home care services across the country. The centres employ nurses and home helpers, who are both required to complete a nationally-licensed training upon hire. Centre employees work as a team to provide services, with nurses leading patients’ care in a coordinating role. Nurses provide services such as blood pressure monitoring, heart checks, bandage changes, wound care and other primary care services. Home helpers assist patients with daily tasks, including managing personal hygiene, preparing meals and cleaning homes. As the concept of home care was foreign to Bulgarians, there was an initial lack of trust from patients and their relatives regarding home care services. It took several months for leaders to explain to communities what the initiative was trying to achieve. In most cases, trust and understanding were built gradually through the consistent provision of high-quality home care services, which enabled patients and communities to see and experience the benefits of home care first-hand. As home care centres rely on donor funding to function, the Bulgarian Red Cross is currently working with the national government to develop a more sustainable financial model for home care delivery. With this goal in mind, a common project between the Bulgarian Red Cross, government ministries and other stakeholders was started in 2012. Currently in the final stages, this joint project is working to establish the necessary political, legal and financial frameworks to fully integrate home care services into the health system and safeguard sustainability.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
Strong leadership from the Bulgarian Red Cross, working in partnership with international organizations such as the Swiss Red Cross and Spitex, propelled the initiative forward. The later partnership formed with the government, and the subsequent stewardship of the Ministry of Health, is working to develop the system conditions required to advance the initiative and fully integrate home care services within the health system.
While quantitative data on outcomes are limited, recently-introduced data collection systems will allow more detailed analysis in the future. Twelve home care centres have been set up across the country, providing services to over 800 elderly patients in total. Integrated health and social services delivered in the community are officially recognized for the first time in Bulgaria and are also included as a priority in national policy documents. As a result, elderly patients now have increased access to primary care services delivered conveniently in their own homes.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
Please click on the link below for more information about this practice.
- Siana Karsheva
- Bulgarian Red Cross