Campaigning for better patient access to opioid medication – the Bulgarian case

With Mr Silvi Gavrilov  |  12 May 2015  |  Print

Campaigning for better patient access to opioid medication – the Bulgarian case

Mr Silvi Gavrilov

Mr Silvi Gavrilov is deputy chairman of the Bulgarian National Patients’ Organisation 


Национална пациентска организация – the Bulgarian National Patients’ Organisation (NPO) – is the largest umbrella patient organization in Bulgaria. The NPO is recognized by the Bulgarian Ministry of Health and works to ensure that the attitudes and opinions of patients are acknowledged and reflected in the health policies of the Bulgarian administration.

The NPO has extensive national representation and it is this large membership that allows its administrative body and staff to obtain first-hand information from patients on a wide range of issues related to healthcare in Bulgaria.

The recent experiences of the NPO, as part of a successful collaborative working group that led to better access to pain medication for Bulgarian patients following the inclusion of these medications on the reimbursement list of the National Health Insurance Fund (NHIF), are presented here.

Access to pain medication

Between 2010 and 2012 the NPO received regular complaints from patients and patient organizations with regard to the reimbursement of pain medication for cancer patients by the NHIF. Under the existing legislation, the cost of all pain medication was reimbursed by the fund only after a patient was admitted to a medical facility. There was no statutory provision that obliged the NHIF to reimburse for pain medication administered at home. The at-home management of cancer patients fell within the scope of this legislation and, unfortunately, hospitals did not have funds available to cover the cost of at-home management of patients’ pain directly.

The impact of this lack of funding meant that hospitals were limiting the number of cancer patients who were able to access adequate medication for pain management, resulting in patients with cancer pain being undertreated throughout the country.

After discussion, the legal department of the NPO decided to seek to modify the legislation so that patients could be reimbursed for the at-home treatment of cancer pain. Given the chronic shortage of funding for medication as part of the NHIF, in order to undertake this legislative change, a collaboration with a number of different stakeholders was required.

Collaborative consultation

The NPO launched consultations with all relevant stakeholders: the Bulgarian Ministry of Health, pharmaceutical companies, the NHIF and healthcare professionals (Figure). Stemming from this initiative by the NPO, a working group was established in order to discuss the legislative changes required. The regular meetings of the working group began in August 2012.

patient access to pain medication

Figure. Collaboration between the NPO and other stakeholders

As a result of the joint efforts of the working group, legislative amendments to Ordinance 40, Article 6, Annex 10 in the section relating to the prescription of opioids were proposed and adopted. These amendments entered into force on 13 April 2013. Since this date, opioids have been 100% reimbursed by the NHIF for the at-home treatment of cancer pain for all patients. This is the first time since its creation in 2000 that the NHIF has agreed to reimburse the cost of pain treatment.

This brief example illustrates the role that long-term collaboration can play in improving the communication between stakeholders in the healthcare system, as well as highlighting the important requirement of the system to respond to the concerns of patients. In addition, as part of this collaboration, the NPO received excellent support from Bulgarian healthcare professionals and from the pharmaceutical industry. Together this collaboration has solved a number of complex problems where legislative amendments were necessary, improving access to effective pain medications for all Bulgarian patients.