Scientific Online Resource System

Scripta Scientifica Salutis Publicae

Clinical pathways - a retrospective view on their application as a financial tool in Bulgarian hospitals.

Lyubomira Koeva-Dimitrova, Elka Atanasova





During 2000-2001, CPs were developed and implemented as a temporary solution for financing the hospitals in Bulgaria. The aim of this article is to study and trace the application of clinical pathways as a tool for hospital funding in Bulgaria.


Material and methods

In order to examine the implementation and the progress of CPs in Bulgarian hospitals we have studied Bulgarian and foreign publications. In addition to this, we also include official reports published by the Ministry of Health, Ministry of Finance, National Health Insurance Fund (NHIF), The National Center of Public Health and Analyses (NCPHA) and others.

Results and discussion

For the first time, CPs are negotiated and included in the National Framework Contract in 2001. Gradually, the number of CPs increased and reached more than 300 in 2015. The introduction of CPs as a tool for financing the hospital care is related to the need of fixing the prices of the respective CPs. Initially, the NHIF and the Bulgarian Medical Association developed a common methodology for fixing the prices of CPs. Since 2011, an amendment to the Health Insurance Act stipulates that the procedures for valuation and payment of activities by NHIF are defined by explicit methodologies. We have found that not all hospitals submit information to the specialized software for hospitals which is the only tool for analyzing the costs structure in the health care establishments at present.


The clinical pathways are not accepted as a sufficient effective mechanism for hospital funding in Bulgaria. Moreover, the lack of accurate and comparable information makes the analyses incomplete and vulnerable.


Clinical pathways ;hospitals; financing; cost pricing; Bulgaria

Full Text



Vanhaecht K, Panella M, van Zelm R, Sermeus W. An overview on the history and concept of care pathways as complex interventions. International Journal of Care Pathways, 2010; 14: 117-123

Johnson S. The development and implementation of pathways in an acute setting. In Wilson J (Ed) Integrated Care Management: The Path to Success? Oxford.Butterworth Heinemann. 1997

Hinkov H, Zahariev B. Twisted Clinical Pathways, Newspaper `Capital`. Available at: (Access on 25 February 2011)

Vekov T, Grigorov M, Dzhabazov S. Clinical Pathways - quality standard of medical activity or tool for financing the hospital care and barrier to accessibility. Medical Review, 2009; vol. XLV (1): 82-84.

Ministry of Health. National Conference on Health Reform in Bulgaria. Verbatim report. Sofia. 1998.

Ministry of Finance. Financing and Health Care Management. Theoretical bases, models, problems and trends. Report. Sofia. Available at: (Access on 25 February 2016).

Ganova-Iolovska M, Geraedts M. Clinical pathways - the Bulgarian approach. Journal of Public Health. 2009; 17(3): 225-230.

National Health Insurance Fund. National Framework Contract for 2015. 2015; Sofia. NHIF.

Ministry of Finance. Analysis of forecast volumes, prices and methodologies for valuation of activities and services in hospital care. Report. Sofia. Available at: (Access on 25 February 2016).

Radeva M. Methodology for valuation and payment for medical activities. Available at:НРД-2015/методики-за-остойностяване (Access on 20 January 2016).

Koeva-Dimitrova L. Problems in reporting the activities of Health Care Establishments. PhD Thesis. University of Economics-Varna. 2013.

Salchev P, Atanasov P, Dimitrova-Savova T. Cost structure of hospitals for period 2012-2014. Economic Thought. 2015; 6: 47-64.

Open Society Institute. Informal payments in the health care system. Report. Sofia. OSI. 2008.

Salchev P, Atanasov P, Dimitrova-Savova T, Griva Chr. Economic analysis and evaluation of the effectiveness of hospital care services in Bulgaria by using the Data Envelopment Analysis for the period 2010-2012. Bulgarian Journal of Public Health. 2013; Vol V (2): 96-128.

State Gazette. Decree No. 94 as of April 24, 2014 for the adoption of methodologies for valuation and payment for medical care. Issue 37 as of April 29, 2014.

Salchev P. Analysis of the relative weights and carrying case mix index of clinical pathways. 2016; DOI:10.1314/RG.2.1.3539.8162

Davidov B. Clinical pathways, Hospitals, National health insurance fund. Republic BG. 2015; Available at: (Access on 23 January 2016).

Griva Chr, Salchev P, Atanasov P, Kundurdjiev T, Dikova K. Analysis of the state and problems of the functioning of the municipal hospitals and the reasons for their closure. Available at: (Access on 11 February 2016)



About The Authors

Lyubomira Koeva-Dimitrova
Varna Medical University

Department of Health Economics and Management

Elka Atanasova
Varna Medical University

Department of Health Economics and Management

Font Size