Bulgaria – EU Parliament Study Report

Country Reports to the European Parliament for:

Discrimination Against Women and Young Girls in the Health Sector

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Bulgaria has the lowest life expectancy of the eight countries reviewed. It also has one of the highest levels of women in the labour force, though this is not always an indicator of economic scale or autonomy. Bulgaria has recently begun to address many of their female focussed health activities as equality issues.

The health programme for women focuses strongly on reproductive and sexual health. Bulgaria has a well-developed system of oncological care, with a wide range of services to detect breast cancer. This may be the reason that death rates from breast cancer are among the lowest of the countries reviewed. Cervical cancer however, remains relatively high, though as it is now

a focus of the recent health planning this may be changing. This level of incidence could be connected with early sexual activity. Bulgaria shows a high number of teenage mothers, an indication that sexual activity probably begins early. The highest percentage of live births were in the under 15, 15-19 and 20-24 year age groups, and this drops sharply (in comparison to other countries) when the older age groups were reached.

There were many areas of research on Bulgaria in which data was not available for comparison with other countries. These included:

  • statistics on age-specific death rates for malignant neoplasms in children aged  0-14,
  • the proportion of women reporting HIV infection, the characteristics of  newly reported HIV infections,
  • data on girls’ perceptions of health and bodyweight, their eating behaviours, and on sexual behaviour.
  • As many of these areas are commented upon in the comprehensive report submitted by Bulgaria, it  suggests that data is available on a local basis and that language and transcription differences may be making this material difficult to access internationally.

The following material was submitted by: Albena Kerekovska, Faculty of Public Health, Medical University of Varna.

Women’s health

Very low crude birth and total fertility rates

Bulgaria has one of the lowest birth rates in the world. From 13.3%o in 1988, births in Bulgaria have declined to 7.7%o in 1997 (the lowest in Europe) and despite the slight increase since late 1990s, it is still one of the lowest birth rates in Europe – 9.0%o for 2004. Total fertility declined from 1.81 in 1990 to 1.29 lifetime births per women in 2004, reaching its lowest rates of 1.09 in 1997 [20]. For the last 15 years it has not exceeded  1.3, which is substantially lower than the level of 2.2 – necessary for replacement of the population.

High teenage pregnancy and birth rates

Bulgaria ranks among the countries in Europe with the highest birth rates in young (adolescent) age of maternity, indicating 1994 and 8.9 per 100 live births in 2002 [17]. inefficient family planning. Related to it is the high proportion of low birth weight births – increasing from 5.7 per 100 live births in 1986 to 7.2 in 1994 and 8.9 per 100 live births in 2002 [17].

High proportion of out of wedlock births

The proportion of out-of-wedlock births has enormously increased for the last decades – from 8% in 1960 to 28% in 1996 to reach the level of over 45% of all live births in 2004 [8,21].

High abortion rates

Abortions have exceeded the number of births since late 1980s until 2000. Although decreasing for the last few years, abortions rates are still high in Bulgaria – about three times the EU average. Particularly high abortion rates are observed in the youngest age groups – up to 20 years of age[2].

The high rate of teenage births and abortions is alarming as well as the decreasing age of first sexual intercourse [8].
Low use of modern methods of contraception
Contrary to the high abortion rates, there is a low rate of using modern contraceptive methods and means for protection from unwanted pregnancy and STDs in Bulgaria [8].

Low life expectancy of Bulgarian women

Bulgarian women have one of the lowest life expectancy at birth in Europe [22] (estimated at 75.9 years for 2005)[21].
High maternal mortality by European standards
Indicators for maternal deaths per 100,000 live births have been unstable for the last 15 years, and yet about 4 times higher than the EU average. Maternal mortality rates are much higher in the rural areas of the country – 25.5 per 100,000 live births than in the urban region – 16.5 per   100,000 live births [17].

Increasing morbidity trends for many diseases

Morbidity rates for gynecological and sexually transmitted diseases, as well as for chronic disabling conditions, such as depression, osteoporosis, diabetes, hypertension, arthritis, metabolic and immune system disorders are rather high among Bulgarian women [17]. The increasing incidence (over 1.5 times for the last 15 years) and the high mortality rates of breast
and cervical cancer are very alarming [20]. A very low proportion of women undergo screening for early detection of these diseases. For the last decade, the incidence of eating disorders (anorexia and bulimia) has been constantly increasing among young Bulgarian girls and women.

High prevalence of unhealthy lifestyle behaviours

Typically, there is a high prevalence of unhealthy behaviour among which smoking, drug and alcohol abuse, unhealthy dietary habits and low physical activity are particularly worrying.

Specific health policies for women

There is neither a separate body coordinating the activities of the different institutions, responsible for the development of the state policy in women’s health and monitoring of its implementation, nor is there a separate Minister, Department or other sort of governmental structure that is specifically devoted to women and health issues. However, a substantial number
of governmental institutions are very much involved in policies and activities relevant to the field, such as: The Healthcare Committee at the National Assembly; The Ministries of Health, Labour and Social Policy, Education and Science, Youth and Sports; The National Centre of Public Health and the National Centre of Health Information; National Social Security Institute; The State Labour Inspectorate and the State Agency for Child Protection; The National Committee of HIV/AIDS and STD Prevention and Control;The Regional Inspectorates of Public Health Prevention and Control with their Health Promotion Divisions, etc. At the same time numerous health, women and youth-oriented non-governmental organisations are very active in the area of women’s health, sexual and reproductive health and family planning.

The main NGOs working in the area are:

The Centre of Women’s Studies and Policies Foundation

Women’s Initiative for Health Foundation;

The Bulgarian Family Planning Association

Gender Education, Research and Technologies Foundation

National Association of Women with Oncology Diseases

Association ‘Women without Osteoporosis’

National Anti AIDS Coalition

Bulgarian Fund for Women

National Association ‘Women in Science’

International Women’s Club of Sofia

Women’s Alliance for Development

Bulgarian Women’s Party

‘Women and health’ is also a part of gender equality issues. Currently in Bulgaria, there is a set of separate structures and institutions addressing gender equality issues (including women’s health).

These are:

  • Institutional Mechanisms to the Legislative (Human Rights and Religious Affairs Committee at the National Assembly – sub-committee on Women’s Rights and Gender Equality; Commission for Protection against Discrimination, reporting to the National Assembly; Parliamentarian Ombudsman, reporting to the National Assembly)
  • Institutional Mechanisms to the Executive (National Council on Equality between Women and Men to the Council of Ministers; National Commission on Combating Trafficking in Human Beings, Equal Opportunities Department at the Demographic Policy; Social Investments and Equal Opportunities Directorate at the Ministry of Labour and Social Policy; Consultative Commission on Equal Opportunities to the Minister of Labour and Social Policy)
  • Institutional Mechanisms at the Local Level (Gender Specialists to the Municipalities; Public Councils to the Municipal Councils; Local Commissions on Combating Trafficking in Human Beings; Local Public Mediators)

 

Gender-sensitive health policy design

Women are an object of particular concern and protection by all state organisations and public institutions related to their health. A substantial number of legal procedures and specific policies have been designed to address women and health issues. Examples are the legislative acts providing special protection of women’s rights and health. Provision of equal access to
healthcare is a fundamental principle of healthcare delivery according to the Law on Health of the Nation [7] with priority however being given to children, pregnant women and mothers. According to this Act, the protection of reproductive health is a major obligation of the State, as women and adolescent girls represent the main focus of the policy in this field. Women in reproductive age, pregnant women and mothers of small children receive special treatment in the National Labour Code [4] and the Health and Work Safety Act [5] with respect to health protection and provision of safe working conditions.   According to the Law on Protection against Discrimination [6], the Council of Ministers formulates State policy and adopts national strategy on gender equality. Equality of women and men in their access to healthcare and preservation of the generative functions of women are treated in the National Action Plan for Promotion of Gender Equality. The principles of gender equality are observed in the conducting of a number of national programmes such as: the National Programme for Prevention of, treatment and rehabilitation of drug addicts (with a view to the generative functions of girls and women); National Programme for Smoking Restraint; National Programme for Mental Health and Action Plan toward it [14]; National Strategy and Work Programme for Preventive Cancer Screening [9] (where breast and cervical cancers are main focus groups).  The National strategy and programme for Treatment and Control of HIV/AIDS and STD also especially focus on young people, adolescent girls and women [11].</P>

A main priority of the National Health Strategy ‘Better Health for Better Future of Bulgaria’ [10] is the reproductive and sexual health of the population where the health of pregnant women, mothers and newborns represent a key strategic area for interventions. Improving the health status and healthcare provision for mothers, pregnant women and adolescent girls is a main strategy goal to be achieved. The reproductive health and sexual culture including education, prevention and healthcare are the highest priorities of also the National Strategy for Bulgaria’s Demographic Development (2006-2020) [2] and the National Strategy for Youth Development.
The predominantly female eating disorders (such as bulimia and anorexia) are partially treated in the National Mental Health Programme and Action Plan and the Action Plans on Food and Nutrition [1,14]. The healthy eating habits and nutrition problems of young girls and pregnant women, as wellas the breast feeding issues, are substantially treated in the National Action Plan ‘Foods and Nutrition’. Women are also among the main risk groups addressed by the National Programme for Limitation of Osteoporosis [19] and the main focus group within the National Family Planning Programme. Another programme that is particularly focused on women is the Maternal Health Programme [13] – aimed at the preservation of women’s health status during pregnancy, birth and post-birth period. It incorporates a package of preventive check-ups,
dispensarisation and treatment activities provided by the GPs and obstetrical specialists and guaranteed by the National Health Insurance Fund budget. Within the Risk Groups Prevention Programme, women at risk for breast and cervical cancer are also receiving special attention and services within the health insurance package.

Women are usually subject to more health research initiatives in relation to their reproductive health, or to diseases typical for the female population, such as osteoporosis, breast and cervical cancer, eating disorders, etc. For instance, one of the main programme directions of the Centre for Women’s Studies and Policy Foundation in Bulgaria is women’s health. However, special protection for women is provisioned by the research legislation [7], as for instance pregnant and breast-feeding women are normally not considered eligible for experimental treatment in clinical trials.

Three primary issues and how they apply to women

Breast Cancer

Breast cancer is the most prevalent oncologic disease in Bulgarian women. Over 36,000 of them currently suffer from it, and the incidence of the disease is constantly increasing with over 3,500 newly registered cases per year. The trends of increasing incidence and mortality rates and the younger age of diseased women are particularly unfavourable. A major problem for the country is the late detection of disease, which explains the high and continuously increasing breast cancer mortality rates (rising from 19.6 per 100,000 women in 1981 to 27.2 per 100,000 in 2000) [17,20].

Oncological diseases and especially breast and cervical cancer are considered a major priority of the national health policy. There are many legislative and regulative documents dealing with the management of these diseases, including the National Programmes for Preventive Cancer Screening and Risk Groups Detection [9]. Many health professionals are involved in the prevention, early detection, treatment and rehabilitation of breast cancer. GPs’ Public Health Care package, for instance, include manual breast examination of women aged 31-69, on an annual basis, and risk assessment. All women included in the risk groups should receive a preventive check-up exam (including mammography) once a year by a specialist (breast surgeon) according to the National Framework Contract (signed annually between the Bulgarian Medical Association and the NHIF) [18]. All these activities are financed by the National Health Insurance Fund (NHIF) and carried out according to the Ministry of Health Ordinance for preventive check-ups and dispensing and the Ordinance for the main package of health activities guaranteed by NHIF budget [15,16]. In all cases where breast cancer is suspected by the clinical examination, mammography and needle biopsy are performed. The obligatory procedures followed in breast cancer detection are: mammography, needle biopsy, excision biopsy, and consideration by the Oncological committee.

The system of oncological care has long been developed in Bulgaria. The complete treatment and care for all oncological (including breast cancer) patients are entirely carried out by the Regional Dispensaries for Oncological Diseases – specialised territorial units providing integrated care to cancer patients. All breast-cancer diagnosed patients are registered in the Dispensary and receive a complete service. These units provide treatment and care at all stages of the disease, from screening through to the care of the advanced disease. They are financed by the Ministry of Health and the National Health Insurance Fund. All therapies and interventions (operative, radiotherapy, chemotherapy, hormone therapy, physical rehabilitation, medication) are covered by the health system. Treatment and care for patients registered in the Regional Dispensaries for Oncological Diseases are free and easy to access.

There are both national and regional surveillance systems of all cancer cases in Bulgaria including breast cancer. The National Centre for Active Oncological Treatment and the Regional Dispensaries for Oncological Diseases (their departments of Cancer Control) are responsible for the registration. Cancer surveillance is mandatory and the data is collected by systematic reporting to the National Cancer Register.

Osteoporosis

In Bulgaria, the magnitude and burden of osteoporosis is not properly assessed. Data on prevalence of disease, its risk factors and complications is incomplete. It is estimated that about 820,000 Bulgarian women have an increased risk for bone fractures. Hospitals’ registries reveal that over 92,000 women have at least one vertebral fracture; every year over 4,000 women suffer hip fractures and 800 of them die within a year due to osteoporotic complications; the average period of hospitalisation after a hip fracture and the ensuing operation is 30-35 days [19].

The only practically functioning programme for now is the ‘Treatment of Osteoporosis with a Pathologic Fracture Programme’ [12], which involves only menopausal women with osteoporotic fractures. The diagnostic and treatment procedures, the specialists’ follow-up exams, and part of the medication for the women included in this programme are covered within the health insurance budget. There are also many specialised healthcare units across the country, which have the necessary equipment and professional expertise for prevention, diagnosis and treatment of osteoporosis; however, as these activities are not covered by the insurance or the state budget, they remain largely unaffordable for the population.

The current situation in the country is characterised by insufficient knowledge of the population in prevention of disease and its complications; unhealthy risky lifestyles; inadequate legislative regulations and access to healthcare facilities; lack of resources for preventative, diagnostic and treatment procedures (i.e. bone densitometry exams are not reimbursed); lack of organised population-based prevention programmes, methodological guidelines and medical standards for applying a complex approach for the prevention, diagnostics and treatment of the disease; large proportion of hidden disease; lack of national information system and osteoporosis register; negligence of primary prevention initiatives and exclusive focus on complications treatment [19]. In recognition of the problem, a National Programme for Limitation of Osteoporosis in the Republic of Bulgaria (2006-2010) has been recently developed to make osteoporosis one of the priorities of the Bulgarian health policy. It aims at: setting the foundations of a coherent national policy for reduction of risk factors for osteoporosis and enhancing protective factors through the implementation of legislative, administrative and public measures to limit the incidence of the disease; estimating the exact number of ill people and people in danger of osteoporosis through setting up a National Information System; improving the access for those who are ill and those at risk of osteoporosis to qualified prevention, diagnosis and treatment [19]. A main target group of the programme is the menopause, pregnant and breast feeding women. The establishment of a national network of 56 specialised centres for prevention, screening, diagnostics, treatment of disease and its complications is planned within the programme, however, resources are not secured and programme activities are not implemented.

Eating Disorders (Anorexia, Bulimia)

The incidence of anorexia and bulimia in Bulgaria is constantly increasing. National data reveals that over 250,000 young girls and women suffer from the disease. At the same time, the state policy and healthcare provisions for this category of patients are completely inadequate and insufficient. There is no a National programme on the prevention, treatment and rehabilitation of these eating disorders. The National Medical Standard on Psychiatric Diseases (a document of the Ministry of Health) does not envision these problems. Moreover, there are no specialised clinics or medical centres for specifically treating such disorders. For the moment, anorexic patients are treated in ordinary out-patient facilities, receiving consultations by a number of specialists (psychiatrist, gastroenterologist, endocrinologist, gynecologist, diet-therapist, etc.). Neither the consultations with the team of relevant specialists, nor the medication treatment are reimbursed by the state budget or the insurance fund. As this treatment is rather expensive, it is usually not affordable for most of the anorexic patients. As there are no specialised inpatient structures for treating these disorders in indications for hospital treatment, such patients are usually treated in the psychiatric hospitals (in wards for addiction problems) or in other hospital wards, according to the complications. Very recently a clinical pathway has been developed for reimbursement of the costs for their inpatient treatment.

A current public and professional debate is going on to discuss the problems of these patients. The Ministry of Health is planning to establish special sectors in the psychiatric hospitals and develop specialised standards and programmes for treating the psychogenic eating disorders. There is pressure also for the establishment of specialised hospital and territorial day-care centres for continuous treatment after hospital discharge. The National Action Plan on Food and Nutrition [1] and the National Programme and Action Plan on Mental Health [14] also have some goals and targets directed at anorexia and bulimia, however, a special national policy and programme on these eating disorders is urgently needed.

 

Specific healthcare policies for young girls

 

There are no healthcare policies designed particularly for young girls in Bulgaria. Healthcare services for young girls are provided mostly by the GPs. Apart from diagnostic and treatment activities, annual preventive check-up exams and health education and promotion activities are also obligatory within the GPs’ Public Health Care package. However, in practice they are not fully implemented. In cases of specialised care needs, young girls are referred by the GP to relevant specialists within the health insurance package. Additional healthcare services are also provided to girls with certain problems and diseases within the National Risk Groups Programme and Chronic Diseases Dispensing requirements, but they are distinguished from the boys with the same problems and at the same age [15].

The admirable tradition of school healthcare services, destroyed during the Health Service reforms, has been recently restored, losing however its predominantly preventive and health promotive orientation. The currently existing school health services are too medically oriented and are exclusively focused on emergency cases occurring at school, such as acute health problems or trauma accidents. There is no systematic health education in schools, including education on sexual and reproductive health, despite the elective health education programmes introduced in the school curricula. The activities in this field depend on the commitment of the school authority, teachers and health care providers. There is a lack of coordination and collaboration between the institutions in the field of sexual and reproductive health promotion, education and service delivery concerning adolescents in schools. Schools health care providers are not well informed about the opportunities for sexual and reproductive health services, which limits the referral choices and efficacy in dealing and solving health and other problems of the adolescents.

Sexual counselling for young girls should be available in all GP and Ob./Gyn. practices but in practicality, in the majority of cas?s, it is not performed. An additional service provided specifically to young girls is the rubella immunisation at the age of 17, which is obligatory within the national immunisation regulations and is covered by the insurance package. Abortion services are freely accessible in Bulgaria. They are free of charge to girls under 18 years of age and can be performed with the informed consent of one of the parents. Other possibilities for receiving heath and sexual education and family planning services are within programmes and projects carried out in the community or school environment, where different NGOs and the health promotion departments of the Regional Inspectorates of Public Health Protection and Control are mostly involved. There is a need for improving the accessibility of health services that meet the sexual and reproductive health needs of adolescent girls, especially in small towns and villages.

 

An example of ‘best practice’ in women’s health

 

An example of well functioning practice in the field of women’s healthcare is the Maternal Health Programme [13], securing free access for each woman to systematic healthcare activities from the beginning of the pregnancy till 42 days after birth delivery. This programme encompasses early registration and systematic medical monitoring of the whole pregnancy by primary and specialised healthcare units and professionals. Pre-natal diagnostics, genetic disease prevention, regular pregnancy monitoring exams and consultations are carried out according to the schedule for the term of pregnancy, depending on pregnancy risk estimation and presentation of specific complications. Home visits by the GP or the specialist are also provided whenever needed. All programme activities are delivered to the women free of charge and are covered within the health insurance package. The concrete activities are regulated in the Ordinances of the Ministry of Health (the Ordinance on Prevention Exams, Dispanserisation, and the Ordinance on Determining the Main Package of Healthcare Activities Guaranteed by the NHIF [15,16]). In normal pregnancies, healthcare is delivered by a GP or a specialist obstetrician, according to the woman’s choice. Increased risk pregnancies are monitored by an obstetrician. There are still some problems with access to specialised outpatient obstetric services in remote rural areas. Birth deliveries in Bulgaria are carried out in specialised obstetric in-patient units with the attendance of an obstetrician. The woman is free to choose the institution. Inpatient healthcare for birth delivery is covered by the insurance package [18].

 

Further examples of Bulgarian initiatives for women’s health

 

Examples of initiatives specifically directed at women’s health can be presented within the following strands:

Legislative initiatives

Women and health’ issues are specifically treated in a number of legal documents, such as the Law on Health of the Nation; the Health and Work Safety Act; the National Labour Code; the National Framework Contract; Ordinances for preventive check-ups, dispensarisation, main packages of healthcare activities guaranteed by the insurance fund budget; specific regulations of human reproduction, family planning, human rights and research activities, etc.

Health care system activities provision

Services developed specifically for women are essentially limited to reproductive needs, especially childbearing, referring to expanding and improving maternal and child health systems. Such services are provided by the outpatient sector (GPs and Gyn./Obst. specialists) and the inpatient facilities (specialised hospitals or wards) within the insurance package or out-of pocket. Family planning counselling and services do not constitute an integral part of reproductive health services. Sexual health education and promotion of the reproductive health of women are important elements in the obligatory package of activities of the Public Health Care system, but are not fully implemented. There is an easy access to free abortion services, while contraceptives are not reimbursed, and are therefore not largely affordable. Women from rural areas throughout the country have particularly limited access to specialised health services.

Initiatives as part of national strategies, programmes and plans for action

Initiatives directed at protecting and improving women’s health are contained in many of the national level strategies, programmes and action plans, such as the: National Health Strategy; National Strategy for Bulgaria’s Demographic Development; National Strategy for Youth Development; National Strategy and Programme for Treatment and Control of HIV/AIDS and STI; National Family Planning Programme; National Food and Nutrition Action Plan; National Action Plan for Promoting Gender Equality; National Programme of Equal Women and Men Opportunities in the Accession to the EU and the Equal Opportunities for Women and Men Monitoring Programme; National Programme for Monitoring Violence against Women; National Programme for Prevention, Treatment and Rehabilitation of Drug Addicts; National Mental Health Programme and National Action Plan toward it; National Strategy and Work Programme for Preventive Cancer Screening; Risk Groups Prevention Programme; Maternal Health Programme; National Programme for Limitation of Osteoporosis, etc.

Research and surveillance initiatives

Studies and surveys on: women and cancer; women’s sexual and reproductive health; medical aspects of trafficking in women; occupational health and women, and others are carried out by state or scientific institutions or within international project activities. Data from the existing System of Vital Registration is also used in epidemiological studies in women’s reproductive health.

Projects, campaigns, seminars, round tables, local initiatives, etc.

The Bulgarian Sexual and Reproductive Health Peer Network was set up as a part of the ‘Strengthening the National Reproductive Health Programme’, a project funded by UNFPA. This involves the elaboration of a comprehensive combined health, sexuality and life-skills educational package for students aged 12-18. This will become part of the school curriculum, and lectures in safe sexual practices, birth control, and HIV/AIDS prevention will be delivered at youth clubs and education centres across Bulgaria.

Through different projects supported by the PHARE Programme of the EU and international organisations like ‘School Health Promotion’, PHARE ‘Family Planning Project’, ‘Youth Education in Bulgaria’, ‘Prevention of STDs and AIDS’ and others, sexual education and health promotion work with young girls and women has been performed.

The Gender Research and Technologies Foundation project ‘Challenging the health reform in Bulgaria: advocacy campaign to include reproductive health services in the social security payments’ has been carried out in order to raise the awareness of decision-makers on the issues affecting the reproductive health of women, and provoke a discussion on the need of inclusion of reproductive health and family planning services in the social security payments. It hopes to convince the decision-makers that they should look for a resolution to the demographic crisis in a proactive way by launching prevention and information programmes for adolescents which will decrease the incidence of teen-age pregnancies and increase the trust in family planning services.

The Bulgarian Family Planning Association plays a significant role in providing sexual education, family planning counselling, and reproductive health services to young people (more than 85% of whom are women). Working actively on the ‘Sexual and reproductive health education in school’ project, the association provides sexual education interactive sessions in schools across the country. Within the project ‘A Call to Osteoporosis Action’ funded by the European Commission, a number of initiatives directed at the limitation of osteoporosis have been performed. A Forum of the Bulgarian Gender Equality Coalition dedicated to the problem of osteoporosis was carried out on the World Osteoporosis Day in partnership with the ‘Women without Osteoporosis’ Association presenting the European initiatives in the area of osteoporosis – reports on the disease, audit report of osteoporosis policy developments and recommendations.

A National Breast Cancer Awareness Campaign is carried out annually within the Breast Cancer Awareness Month – seeking to raise public awareness for prevention and cure of breast cancer, and funds for educational and preventive activities and the provision of equipment (mammographs) for the more remote parts of Bulgaria. A round table discussion ‘The costs of women’s reproductive health in Bulgaria’ was organised by the Gender Education, Research and Technologies Foundation as a part of a larger international campaign in CEE of the ASTRA network for sexual and reproductive health and rights of women.

 

Further gender influences on patterns of health

 

Gender differences in the health of the Bulgarian population can be summarised as having the following characteristics:

Crude and age-specific mortality rates distinctions

The crude and age-specific mortality rates are considerably higher in men than in women in all age groups. The age group at most risk is men between the ages of 40-59 years, whose death rates are much higher than those for women. In 2002 for instance, the number of deaths for women during that age span represented 16.4% of all female deaths, whereas this proportion was two times higher for men – 31.5% [3]. The proportion of increase in the death rate is also higher among the male population.

Life expectancy indicators

There is a growing gap between male and female life expectancy at birth. Since the mid 1960s the male mortality rate, particularly that of men who should be in their prime, has increased – negatively impacting upon life expectancy figures, while female life expectancy stagnated. In 1970, there was a one year difference between the two sexes. Now it is about 6.5 years in favour of women (68.9 years for men and 75.6 for women for 2004 [17,22]. While life expectancy has been slowly increasing since 1998, healthy life expectancy has been declining for the two sexes and all age groups, and is lower than the average in EU countries. Data for 2000 reveals 60.8 years HALE at birth for the male and 65.2 for the female population [17].

Disease specific morbidity and mortality gender distinctions

Bulgarian men have higher morbidity and mortality rates than Bulgarian women for circulatory system diseases (1009.4 per 100,000 men against 927.5 per 100,000 women for 2003)[17]. Data on stroke incidence and death rates reveals a marked gender and regional gradient from very high rates in males living in rural areas, to less elevated rates in females living in urban areas. Men also have significantly higher morbidity and mortality rates from respiratory and external diseases (i.e. accidents and poisonings) than women. Lung cancer deaths, for instance, have risen only slightly for the female population since the 1970s, while rising steeply for middle-aged males. Standardised Death Rates (SDR) for external causes are higher for the male (83.9 per 100,000 in 2002) compared with the female population (25.8 per 100,000) [17]. Heart attack incidents in men are two times higher than women. Gynecological and sexually transmitted diseases, as well as some chronic disabling conditions, such as cancer, depression, osteoporosis, diabetes, hypertension, arthritis, metabolic and immune system disorders represent a major cause of morbidity and mortality among Bulgarian women. The increasing incidence (over 1.5 in the last 15 years) and mortality rates of breast and cervical cancer are very alarming. For the last decade, the incidence of eating disorders (anorexia and bulimia) has been constantly increasing among young Bulgarian girls and women. As a result of these diseases and women’s health behaviour, the incapacitating morbidity in women is higher than in men.

Health-related behaviours gender differences

Some health-related behaviours are more prevalent in men, such as smoking, alcohol and drug abuse, whereas physical inactivity and unhealthy dietary habits prove to be more common among the female population. Women are more likely to show healthcare seeking behaviour than men.

Main reference documents:

1. Council of Ministers (2005) National Action Plan ‘Foods and Nutrition’ of the Republic of Bulgaria (2005-2010).

2. Council of Ministers (2006) National Strategy for Bulgaria’s Demographic Development (2006-2020) links not working.

3. Golemanov, N. (2000) The sex differences in mortality: biological fate of lifestyle. Review of the Institute of Demography. Bulgarian Academy of Science. Population, Anniversary Issue, pp. 47-61 (in Bulgarian).

4. Government of Bulgaria (1986) Labour Code. Official State Gazette No. 26 of 1.04.1986 and No. 27 ?f 4.04.1986.

5. Government of Bulgaria (1997) Health and Work Safety Act. Official State Gazette No. 124 of 23.12.1997 (Accessed at: link not working ).

6. Government of Bulgaria (2003) Law on Protection against Discrimination. Official State Gazette No. 86 of 30.09.2003.

7. Government of Bulgaria (2004) Law on Health of the Nation. Official State Gazette No. 70 of 10.08.2004.

8. Marinova, J., R. Stamenkova (2005) Reproductive health services in Bulgaria: a country report. ASTRA – Central and Eastern European Women’s Network for Sexual and Reproductive Health and Rights publication (no longer available – was removed by Astra).

9. Ministry of Health (2001) National Strategy and Work Programme for Preventive Cancer Screening in the Republic of Bulgaria (2001-2006).

10. Ministry of Health (2001) National Health Strategy. Better Health for a Better Future of Bulgaria. Sofia.

11. Ministry of Health (2001) National Programme for Treatment and Control of HIV/AIDS and STD (2001-2007).

12. Ministry of Health (2003) ‘Treatment of Osteoporosis with a Pathologic Fracture’ Programme (Accessed at: …more).

13. Ministry of Health. (2003) Maternal Health Programme.

14. Ministry of Health (2004) The National Programme on Mental Health for the citizens of the Republic of Bulgaria and Action Plan towards it (2004-2012).

15. Ministry of Health. (2004) Ordinance No.39 on Prevention Exams and Dispanserisation of 16.11.2004.

16. Ministry of Health. (2004) Ordinance No. 40 on Determining the Main Package of Healthcare Activities Guaranteed by the NHIF of 24.11.2004.

17. Ministry of Health (2004) Report on the Health of the Nation at the beginning of the 21st century. Analysis of the health care reform.

18. Ministry of Health (2006) National Framework Contract (2006).

19. Ministry of Health (2006) National Programme for Limitation of Osteoporosis in the Republic of Bulgaria (2006-2010).

20. National Statistical Institute, National Centre for Health Informatics, Ministry of Health, Public Health Statistics Annual, Sofia (various years, 1970-2004).

21. UNFPA. (2005) Country profiles for population and reproductive health: policy development and Indicators: Bulgaria.

22. World Health Organisation (2005) European Health for All Database. Copenhagen: WHO Regional Office for Europe.

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