The Bulgarian Model of Integrating Military and Civil Health Care System

1. The Bulgarian Model of Integrating Military and Civil Health Care System Lt.C. (R), Assoc. Prof. Kamen KANEV MD PhD, Brig. Gen. Prof. Stoyan TONEV MD PhD, Col. (R), Prof. Dimitar LEKOV MD PhD MILITARY MEDICAL ACADEMY, SOFIA, BULGARIA

2. The reform of the Bulgarian Healthcare System has both a social and health price for the civilian population and major significance for the development of the Bulgarian military and civil medicine as a whole.

3. The aim of this study is to investigate the integration of the Military and Civil Healthcare System while the Reform in the Health Care System takes place in order to diminish the negative social and health effects on the civil population.

4. Under the conditions of reforming Civil Healthcare System, Military Healthcare System, especially Military Medical Academy resolves not only military medical tasks and problems in the country and abroad but opens its doors to the civilian population in the whole country.

6. MISSIONS MILITARY MEDICAL ACADEMY IS A MULTI-PROFILE MEDICAL FACILITY STRUCTURED TO PROVIDE BULGARIAN ARMED FORCES WITH UP-TO DATE MEDICAL CARE FOR THE SOLDIERS, AND TO ACT AS A PART OF THE NATIONAL HEALTHCARE SYSTEM DECREE OF COUNCIL OF MINISTERS #119/13.06.2002 GOALS ACCOMPLISHMENT OF THE HEALTH REFORM IN MEDICAL SUPPORT IN ACCORDANCE WITH MILITARY DOCTRINE AND PLAN 2004 ACHIEVEMENT OF THE REQUIRED CAPABILITY TO PROVIDE MEDICAL SUPPORT TO THE FORCES ACCORDING TO NATO STANDARTS

7. MMA-MOD MEDICAL FACILITIES FOR OUT-PATIENT AND IN-PATIENT CARE ADMINISTRATION Departments, chairs, clinics, laboratories - therapy - surgery -neurology, psychiatry, neurosurgery - image diagnosis - laboratory - emergency and intensive care - healthcare operations - disaster medicine Center for military medical expertise and aviation medicine Research Center for radiological, biological, and chemical protection Rehabil Hospitals - Hissar - Pomorie - Bankya Center for military epidemiology and hygiene MIL H - Plovdiv Mil Med Det Em Res with branches MIL H - Varna MIL H - Sliven MIL H - Pleven Medical Department - GS Medical Department Army HQ Medical Department AF HQ Medical Department Navy HQ Central Depot Lovech Troop medical units Troop medical units Troop medical units

8. SPECIFIC TASKS • DIAGNOSIS, TREATMENT AND REHABILITATION FOR ALL WHO NEED MEDICAL CARE FROM THE ARMED FORCES AND CIVILIAN POPULATION • PROPHYLAXIS OF DISEASES AND INJURIES//PREVENTIVE MEDICINE SANITARY CONTROL ENVIR. CONTROL/ • MEDICAL SUPPORT OF COMBAT TRAINING AND PHYSICAL TRAINING • MEDICAL EXPERTISE OF FITNESS FOR MILITARY SERVICE • SCIENTIFIC RESEARCH IN MILITARY MEDICINE • MILITARY MEDICAL TRAINING AND POSTGRADUATE MEDICAL TRAINING • READINESS FOR CRISIS RESPONSE OPERATIONS • MEDICAL SUPPORT OF MISSIONS ABROAD /INTEROPERABILITY WITH NATO COUNTRIES/ • MEDICAL EVALUATION • MEDICAL LOGISTICS • ELABORATION OF MEDICAL KITS AND MODULES

9. STRUCTURE OF MMA • MULTI-PROFILE HOSPITAL BASE FOR ACTIVE TREATMENT – SOFIA • HOSPITAL BASES FOR ACTIVE TREATMENT – VARNA, PLOVDIV, PLEVEN, SLIVEN • HOSPITAL BASES FOR BALNEOLOGY, REHABILITATION AND PROPHYLAXIS – HISSAR, POMORIE, BANKYA • CENTER FOR MILITARY MEDICAL EXPERTISE AND AVIATION MEDICINE • CENTER FOR MILITARY EPIDEMIOLOGY AND HYGIENE • RESEARCH CENTER FOR RADIOBIOLOGICAL, BIOLOGICAL AND CHEMICAL PROTECTION • MILITARY MEDICAL DETACHMENT FOR EMERGENCY RESPONSE / URGENT MILITAY MEDICAL UNIT/ • TROOP MEDICAL UNITS

10. PERSONNEL and NUMBER OF BEDS • MEDICAL DOCTORS – 300 • DENTISTS – 5 • NURSES – 460 • OTHER PERSONNEL – 555 • PROFESSORS – 8 • ASSOC. PROFESSORS – 44 • ASSISTANT PROFESSORS – 38 • DOCTORS OF SCIENSES – 10 • DOCTORS - 64 • MPHBAT -SOFIA 581 • HBAT-PLOVDIV 120 • HBAT-SLIVEN 100 • HBAT-VARNA 280 • HBAT PLEVEN 100 • HBBRP-BANKYA 120 • HBBRP-HISAR 215 • HBBRP-POMORIE 150

11. With its five hospital facilities for active treatment in Sofia, Plovdiv, Varna, Pleven, Sliven, as well as the hospital facilities for continuous treatment and rehabilitation in Bankya, Hissar and Pomorie, the Military Medical Academy provides highly qualified and specialty diagnostics, treatment, rehabilitation and prophylaxis of military and civilian patients in the entire country.

13. HOSPITAL FACILITY FOR ACTIVE TREATMENT (HFAT) - VARNA A hospital with 280 beds and a diagnostic-consulting block, providing full range of specialized medical services for the military contingent and the civil population of North-Eastern Bulgaria. At HFAT – Varna, there are established: Clinic of Internal Diseases, Department of Surgery, Clinic of Orthopedics and Traumatology, Clinic of Toxicology, Thermal Trauma Ward, ENT Ward and Ophthalmologic Ward. The excellent equipment and the high-qualified specialists allow HFAT – Varna to be a referral hospital for thermal trauma and intoxication treatment for the North-Eastern region of Bulgaria, and an educational base for the Medical University of Varna.

14. HOSPITAL FACILITY FOR ACTIVE TREATMENT - PLOVDIV The Hospital Facility for Active Treatment – Plovdiv is a health establishment with 100-years history and rich traditions in the structures of the Bulgarian Army. The health reform enabled the hospital to sign a contract with the Health Insurance Fund and to render health care to all who wish. The hospital has an Admission-Consulting Block, where 8 functioning rooms (therapeutic, neurological, surgical, orthopedic, ENT, dental, and dermatological), diagnostic laboratories (Clinical Analyses Ward, Pathology Ward, Microbiological Laboratory), as well as Image Diagnostics Ward.The hospital has 120 beds in 8 clinic units: Internal Medicine Clinic, Clinic of Surgery, Clinic of Neurology and Psychiatry, ENT Ward, Dermatology and Venereal Diseases Ward, Ophthalmologic Ward and Physical Therapy Ward.HFAT - Plovdiv, as a branch of the Military Medical Academy-Sofia uses preferentially the diagnostic and therapeutic capacities of this leading healthcare establishment in the country – nuclear magnetic resonance imaging, computer tomograph scanner, lithotripter, hyperbaric chamber, etc.

15. HOSPITAL FACILITY FOR ACTIVE TREATMENT (HFAT) - PLEVEN HFAT is established in 1903 by a Decree of King Ferdinand as a Ninth Division Hospital for the purpose of medical provision of the army in Central North Bulgaria. This is a commitment the hospital has performed till present. The following units are functioning at HFAT - Pleven: diagnostic-consulting block and wards of surgery, internal diseases, neurology, physical therapy, anesthesiology and intensive care. Along with the regulatory assigned contingent, civilians may get healthcare at the hospital under the clinical pathways contracted with the Health Insurance Fund (asthma, diabetes, inguinal hernia, cardiac rhythm disorders, acute appendicitis, pneumonia, heart failure, chronic obstructive pulmonary disease, chronic diseases of tonsils).

16. HOSPITAL FACILITY FOR ACTIVE TREATMENT (HFAT)- SLIVEN Hospital Facility for Active Treatment in Sliven is integrated part of the MMA, providing healthcare to the military contingent of Southeastern Bulgaria.It has Diagnostic Consulting Block including: X-ray ward, Functional Diagnostics, Laboratory and Consulting-Reception Rooms. The Stationary Block has 100 beds in 12 wards: Surgery, Emergency and Septic Surgery, Urology, General Therapy, Cardiology, ENT, Anesthesiology Reanimation and Intensive Care Unit, Infectious Diseases, Physiotherapy and Pathology.Civilians have the right to be treated in HFAT - Sliven under the 23 clinical pathways contracted with the Health Insurance Fund

17. HOSPITAL FACILITY OF BALNEOLOGY, REHABILITATION AND PROPHYLAXIS – BANKYA The major sanative factors of the town of Bankya are the mineral waters (hydrothermal, hydrocarbonate-sulphate-sodium, silicon and lightly fluorized) and the climate (moderate continental with foot-of-mountain influence). The hospital facility of Bankya is specialized in treatment and rehabilitation of cardio-vascular and brain diseases and post-surgery conditions: valvular heart diseases with heart failure up to 1st degree; cardiac defect post-surgery conditions; ischemic heart disease; conditions following myocardial infarction, compensated forms of myocardial dystrophy, 1-2 stage hypertension disease; atherosclerosis in early stage, angioneurosis and 1-2 stage Raynaud's disease; 1-2 stage Burger's disease; atherosclerotic arterial obliteration of extremities - up to the 2 stage; functional disorders of nervous system.A favorable influence is observed in some light forms of thyreotoxicosis, light forms of diabetes, obesity, chronic neuralgia and neuritis, chronic gastritis and colitis, light forms of arthro-rheumatic diseases.

18. HOSPITAL FACILITY OF BALNEOLOGY, REHABILITATION AND PROPHYLAXIS "KALEROYA" - HISSAR Town of Hissar is a famous health resort, located at the foot of the Sredna Gora Mountains, established in the fifth millennium B.C. around the mineral springs by the Tracian tribe of Bessi. Hissar mineral waters have low level of mineralization, being hydrocarbonate-sulphate-sodium waters, containing a small amount of radon, fluoride, hyperthermal and moderately alkaline. They are recommended for the treatment of: kidney stones, chronic pyelonephritis, chronic cystitis and urethritis, post extracorporeal lithotrypsy state, single kidney, chronic renal failure - initial stage; chronic gastritis, gastro-duodenitis, functional gastric disorders, dyspepsia, chronic non-specific enterocolitis, peptic ulcer disease; gallstones, chronic cholecystitis; biliary dyskinesia, post viral hepatitis' states; metabolic syndrome, obesity, diabetes, gout, arthro-rheumatic diseases; inflammatory gynecological diseases; discopathy, radiculitis, polyneuritis.

19. HOSPITAL FACILITY OF BALNEOLOGY, REHABILITATION AND PROPHYLAXIS "ST. GEORGE THE CONQUEROR" -POMORIE The town of Pomorie is a talasso-, pelo- and climate-therapy resort, located upon a slightly elevated peninsular to the north end of Burgas gulf, established in the VI-V century B.C. The most precious treasure of the town is the world famous Pomorie healing mud, favourable for treatment of: arthrosis, arthritis, states post traumas and fractures; neuritis, radiculitis, disk herniation disease, pediatric cerebral palsy; sterility, dismenorrhea, ovarial hypofunction, parametritis; prostatitis, olygospermia, epididimitis, vesiculitis; psoriasis, psoriatic arthritis, hypothrophic skin lesions; bronchitis, sinusitis. In the hospital facilities a complex treatment is carried out with Pomorie mud, lye treatment, a rich scope of physiotherapeutic procedures, kinesitherapy, acupuncture, body building, aromatherapy, inhalation treatment, laser therapy, underwater jet massage, solarium, anticellulitis program, sauna, thalassic therapy.

20. TOTAL NUMBER OF PATIENTS IN MILITARY MEDICAL ACADEMY FOR 2003

21. Military Medical Academy is entitled with priority to provide emergency and immediate health care in the fields of the emergency medicine, radiology toxicology and infectious and parasitic diseases.

22. The Military Medical Academy operates in crisis situations through Military Medical Detachment for Emergency Response (MMDER) including personnel of three of the hospital facilities of MMA: in Sofia, Plovdiv and Varna. PURPOSE: TO PROVIDE QUALIFIED AND PARTLY SPECIALIZED MEDICAL CARE IN THE EVENT OF NATURAL AND MAN-MADE DISASTERS IN PEACE TIME FOR MEETING THE MEDICAL NEEDS OF CIVIL POPULATION

23. SPECIFIC MILITARY UNITS FOR EMERGENCY RESPONSE • 2 HELICOPTERSMI – 17 LIFTING CAPABILITY- 6 LITTERS • 1 FIXED WING AIRCRAFT AN – 26 LIFTING CAPABILITY- 10 LITTERS + 10 SITTING PATIENTS

24. Disposition of personnel and levels of medical care 10 PERSONNEL ROLE 1 MMDC 58 PERSONNEL ROLE 2+ 12 PERSONNEL ROLE 1

25. IN CASE OF MASS CASUALTY SITUATIONS MILITARY MEDICAL ACADEMY PROVIDES: TEMPORARY CENTER FOR TREATMENT OF PATIENTS WITH ACUTE RADIATION SICKNESS; TEMPORARY CENTER FOR TREATMENT OF INTOXICATED PATIENTS; CENTER FOR TREATMENT OF INFECTIOUS AND PARASITIC DESEASES; TEMPORARY TRAUMA CENTER.

26. As a recognition for good management, the MMA took an efficient management of five more medical facilities: two hospital facilities for continouous treatment and rehabilitation in Narechen and Velingrad, and three diagnostics and consultation centers in Haskovo, Stara Zagora and Burgass.

27. BULGARIAN MILITARY MEDICAL MISSIONS RUSSIA - JAPAN 1903-1905 CAMBODIA 1992-1993 Romania W. W. I 1914-1918 BOSNIA AND HERZEGOVINA 1997-CONTINUE W. W. II 1941-1945 F.Y.R.O.MACEDONIA APRIL-JULY1999 Serbia Black Sea KOREA 1952-1956 TURKEY 18-24 AUGUST 1999 Sofia VIETNAM 1956-1971 KOSOVO 2000- CONTINUE ALGERIA 1962-1990 AFGHANISTAN 2002 - CONTINUE Macedonia Turkey MOZAMBIQUE 1978-1986 ANGOLA 1983 Greece NICARAGUA 1980-1981 ETHIOPIA 1978 SYRIA 1980-1990 LEBANON JULY-AUGUST 1981 ARMENIA 1989-1993 ROMANIA 25-29 DECEMBER 1989 LIBYA 1979

28. In conclusion we can state that the Health Care Reform in R. Bulgaria underwent successfully thanks to the integration of Civil and Military Healthcare System and especially Military Medical Academy thus decreasing the social and health price payed by the civilian population.