Social support systems
Organisation and financing of social support to people with dementia and carers
Background information on the social/healthcare system in Bulgaria
Until 1990, Bulgaria had a Communist government. This was replaced in 1991 by a multiparty parliamentary democracy, governed by a single chamber with a president as head of State. Prior to 1991, Bulgaria had a Semashko kind of health care system (a centralised, tax-based system). Although it became clear that certain elements of this system were problematic, it was not until 1997, when the health care system seemed to be in danger of collapsing, that measures were taken to rationalise the system and improve the effectiveness of health care provision. Social health insurance was introduced at the end of the 1990’s but out-of-pocket payments remain a problem for people on a lower income (Koulaksazov et al., 2003).
The organisation of social support for people with dementia and carers
Specific support for people with dementia and their carers is not available in Bulgaria. However, people with mental disorders can attend social houses which are financed and supported by the State. Unfortunately, the conditions in these social houses are often poor.
The current European trend is to encourage people with dementia to remain with their families but the appropriate services and support are not available due to a lack of regulations and of practical and financial support for carers.
Social support is organised by the Ministry of Labour and Social Policy and by the Agency for Social Support. This is general social support which people with dementia can benefit from but to do so, they have to have the necessary health certification as without this, they are not eligible for social support. The house doctor in coordination with a specialist doctor prepares a set of documents for a special Commission (???????????a ????????a ???????a ??????? (????) – Territorial Expert Medical Commission), which certifies the level of disability and the Municipality supplies the social support according to the Regulations of the Agency for Social Support.
The Ministry of Labour and Social Policy does not accept responsibility for people with dementia. Although it is responsible for the homes for people with dementia, the administration of this Ministry, which has direct responsibility for these homes, tries to transfer responsibility to the Ministry of Health (which only covers medical treatment) on the grounds that the people in these homes are ill.
As a result of pressure from the European Union and with the help of financial support, some projects are now underway. Unfortunately, they are too generalised and are dedicated to people with mental disabilities. They do not cater for the needs of people with dementia. Compassion Alzheimer Bulgaria recently submitted a project proposal entitled “deinstitutionalisation through the provision of community-based services for risk groups” but this was classified as not relevant or important for Bulgaria and therefore rejected.
Cooperation between the State and the private sector, voluntary associations and NGOs is progressing very slowly. Currently, support for people with dementia is insufficient and constructive cooperation between the State and the above mentioned parties, which is necessary to resolve this problem, is clearly lacking. In fact, the Ministry of Labour and Social Policy avoids a constructive dialogue and cooperation with Alzheimer Bulgaria.
The overall funding of social support for people with dementia and carers
Social houses are 100% funded by the State through general taxation. There are places for about 800 people in Bulgaria and the cost is about EUR 100 per person per month. This is paid by the State. Service users do not pay anything.
Social services (i.e. the provision of food and home cleaning) are only partly financed by the State in that the State pays 20% of the cost and the person with dementia or his/her family pay the remaining 80 %.
Social houses and social services are supposed to be funded through general taxation.
The legal framework surrounding the provision of social support
There is no specific law covering support for people with dementia or their carers. People with dementia are covered by legislation for people with disabilities who need some kind of social support.
The Law on Social Support – 19.05.1998r (????? ?? ???????? ???????????- 19.05.1998 ?) deals with social support in general. The Regulation of 5.11.1998 covering the application of the Law on Social Support (????????? ?? ????????? ?? ?????? ?? ???????? ??????????? ????? ? ??? ? 243 ?? 5.11.1998 ?) is also relevant.
The problems of people with dementia are covered by the Decree N: 4 – from 16.03.1999 on the Requirements and Supply of Social Services (??????? ? 4 ?? 16.03.1999 ?. ?? ????????? ? ???? ?? ?????????? ?? ???????? ??????). This is a common regulation relating to the kinds of services provided, minimum standards and the control of these services.
The suitability of social support for people with dementia and carers
Adequacy and accessibility in general
None of the existing social services are specifically designed for people with dementia. Only general services are available which cater for general needs, not those that are specifically related to dementia.
The provision of social services throughout Bulgaria is insufficient. Consequently, people with dementia have difficulty accessing them.
The State does not provide sufficient funds to ensure adequate services in social houses. For this reason, social houses are frequently situated in isolated, rural areas where it is difficult to find qualified staff.
People living in rural areas
As stated above, social houses are often situated in rural areas rather than in larger towns.
People with different types of dementia
There are no services that are aimed at people with specific types of dementia.
People from ethnic minorities
There are no services that are specifically aimed at people with dementia or carers from ethnic minorities.
Younger people with dementia
Access to most social services is based on disability rather than age, but home help and the meals service are both for the elderly so younger people with dementia would presumably be excluded.
Services and support for people with dementia and their carers
Types of care
There are no day care centres in Bulgaria. There are, however, day care centres for young disabled people but they are not suitable for people with dementia.
Respite care in the home and short-term respite care services do not exist.
Long-term residential care
However, long-term residential respite care (in social houses) does. This is completely funded by the State which pays EUR 100 to EUR 120 on average per person. Staff in such care centres are usually inadequately trained. Most of the people who benefit from such care are there because they are not cared for by relatives. Many have no diagnosis. The Bulgarian Alzheimer Association considers this service insufficient and plans to organise training for staff in these establishments.
There are no palliative care centres or provisions for palliative care at home in Bulgaria.
Monitoring in the home via alarm systems
There are no tele-alarm systems whereby a person can signal for assistance in case of emergency.
Personal assistance and home help
Private companies provide assistance with personal hygiene, eating and drinking, as well as supervision taking medication. These services are not specifically designed for people with dementia and are financed totally by the service users.
The following services are not available:
- Assistance with mobility e.g. lifting, moving and walking
- Assistance dealing with incontinence
- Assistance with skin care e.g. hydration, preventing and dealing with bedsores
- Companionship and social activities
- Occupational therapy/ergotherapy
- Assistive devices
Assistance with housework (e.g. cleaning the home) and with the preparation of food (or delivery of meals to the home) is a social service provided to the elderly. The State only contributes 20% towards the cost of this service. The remainder must be paid by service users (or by their carers). Shopping, transportation and laundry services do not exist.
The Bulgarian Alzheimer Association considers that the existing social services covering personal assistance and home help are insufficient.
Psychosocial support and training for people with dementia and carers
A general information service to direct people towards the services they need does not exist. However, there is a general clinical psychologist in every main hospital who can provide such information. He/she would be partly paid by the State and partly by the service user. The Bulgarian Alzheimer Association provides more specialised information through publications and its telephone help-line. The Association tries to make use of existing information channels i.e. the Administration of Social Houses, doctors, specialists in the field, State institutions, people with dementia themselves and their carers.
There are no counselling services or support groups for people with dementia or their carers. Similarly, there are no services which organise holidays for people with dementia or their carers, or which provide substitute carers to enable the latter to organise their own holidays or time off caring.
Work/tax related support for people with dementia
There is no legislation relating to the rights of people with dementia in paid employment e.g. to protect their job security and social rights.
People with dementia who receive a pension are entitled to a supplement to purchase services on the basis of disability provided that they have the necessary health certification. The actual amount received depends on their level of disability. They are not entitled to tax refunds or other financial incentives for employing a person to provide home care services or to pay for necessary home adaptations.
People with dementia are entitled to reductions for telephone and transport services but do not benefit from subsidised or free television or radio licences.
Work/tax related support for carers and carer allowances
Carers are not entitled to any paid time off work or flexible working hours in order to organise more effectively the care of a person with dementia. They can, if they wish, try to negotiate with their employer unpaid time off work but this is not covered by any specific legislation.
Carers do not receive any direct or indirect payments from the State for caring and they are not entitled to any tax benefits/incentives for the care they provide.
The State does not pay or contribute towards the State pension scheme when a carer gives up paid employment in order to care for a person with dementia.
Unless otherwise stated, the information in this report was provided by Ms Zvezdelina Triffonova and the Bulgarian Alzheimer Society (Compassion Alzheimer Bulgaria) in May 2007
- Koulaksazov, S., Todorova, S., Tragakes, E. et al. (2003), Health Care Systems in Transition, Bulgaria, http://www.observatory.dk
- Datzova, B. (2003), Health care reform and inequality in access to health care in Bulgaria, (Draft paper prepared for the RUIG/UNRISD project on Globalization, Inequality and Health, a collaborative international project forming part of the RUIG research programme on The Social Challenge of Development), http://www.ruig-gian.org/ressources/comeliau-health_Bulgaria-Datzova.pdf
- Law on Social Support (in English): http://www.bcnl.org/doc_en.php?DID=309
Last Updated: mercredi 15 juillet 2009