This case study illustrates the importance of improving the leaving conditions and promoting social integration of vulnerable groups such as the Roma population. Bulgaria’s regional development operational programme is also a good example of how health inequalities can be addressed within the framework of Structural Funds interventions, not only by enhancing access to health care for everyone but also by improving accessibility of other relevant services (e.g. transport, public buildings...).

The main reference document for the preparation of the Operational Programme Regional Development was the National Strategic Reference Framework (2007-2013). The Ministry of Regional Development and Public Works coordinated the development of the program and became its Managing Authority. There are no intermediary authorities in the sense of Council Regulation 1083/2006 and thus the management and implementation of the OP is granted to the MRDPW. A working group was set up for the purpose of preparation of the OPRD. About 50 relevant stakeholders took part in the elaboration of the program.

Although thecooperation between stakeholders was considered satisfactory and the Ministry of Health was involved, a thorough review of potential health impacts of the planned investments was not carried out as part of the development process. In the OPRD health considerations are directly acknowledged in the context of healthcare investments; public health gains from non-health investments are not directly considered.  The consulted experts claimed that public health gains are accordingly reflected in other aspects of the OP, including sustainable development, environment, integration of disadvantaged communities, accessibility to services by people with disabilities, etc.

The OPRD gives priority attention to the social, educational and health problems of Roma minorities and measures for preserving the Roma cultural identity, as part of an overall goal to improve the social inclusion of disadvantaged and vulnerable urban communities. The OPRD also has a focus on activities ensuring better accessibility to health by improving connectivity to health centres as well as equal opportunity and access to transport, public buildings and services for disabled people.

It is not expected that the public health impacts of non-health interventions will be considered in a more coordinated and systematic way under the ongoing new programming process which will require a review of current practices in this respect. Such a review can be ensured through a straightforward and targeted guidance, or (better) an explicit obligation within the EU Cohesion Policy regulations or guidelines for the preparation of the OP.

This deficiencies call for a number of actions including better inclusion of public health aspects in the planning of the OP in a structured and coordinated manner.The development of comprehensive guidance, targets, and indicators was identified as crucial to ensure necessarytools to assess potential health gains of Structural Funds investments.It will be a precondition in the context of Bulgaria to put forward to relevant authorities in the form of requirements from EC or laid down in a the legislation, their obligation to reflect on public health aspects in order to ensure the observance of public health gains.



Background information

Bulgariais situated in the South-East part of Europe on the Balkan Peninsula covering an area of 110,993.6 km2. The total population of Bulgaria is 7.35 million (2011).[1] Bulgaria borders five countries and the Black Sea defines the extent of the country to the East.

Bulgaria joined the European Union in 2007 and the 2007-2013 period is thus the first one in which the country benefits from Structural Funds assistance. For the ongoing funding periodBulgaria has been allocated some €6.9 billion, of which €6.7 billion under the Convergence Objective and €179 million under the European Territorial Cooperation Objective.

The Bulgarian Government established six NUTS II regions (Severozapaden, Severentsentralen, Severoiztochen, Yugozapaden, Yuzhentsentralen and Yugoiztochen) to comply with the EU regional policy requirements and in accordance with the provisions of EC Regulation No. 1059/2003 on the establishment of a common classification of territorial units for statistics.All of these NUTS II regions have a per capita GDP of less than 75% of the EU average. They are therefore all eligible for funding from the Structural Funds under the “Convergence” objective.

The management of all Operational Programmes (OPs) is exclusively centralised within the competence of the central governmentin order to ensure an integrated approach towards EU funding with respect to planning and implementation. Bearing in mind this particular approach towards management of the funds in Bulgaria, this case study will consider the Operational Programme for Regional Development (OPRD). The Ministry of Regional Development and Public Works (MRDPW) is the Managing Authority (MA) of the OPRD. Managers and experts of the MRDPW provided inputs to the completion of this case study report.   

Table 1: Bulgaria: the six Convergence regions at-a-glance

Figures from 2007


Severen tsventralen



Yuzhen tsentralen


Population (inh.)

0.93 m

 0.93 m

 0.99 m

1.13 m

1.55 m

2.12 m

Surface area (km2)







GDP per capita in EUR (PPS)







GDP per capita as % of EU 27 (PPS)







Cohesion Policy status







Life expectancy at birth, male







Life expectancy at birth, female







Sources: Eurostat and Fifth report on economic, social and territorial cohesion

Figure 1: Bulgarian regions, by Cohesion Policy status, 2007-2013

Source: DG Regional Policy – Inforegio                                                                                                       

Per capita GDP in Bulgaria differs considerably across the regions, ranging between 27% and 67% of the EU average. Bulgaria’s national per capita GDP is the lowest of all EU Member States.

Figure 2: GDP per capita in PPS (EU27 average = 100)

Source: Eurostat; GDP per capita in PPS is Gross Domestic Product in purchasing power standards.

In 2007, life expectancy at birth in Bulgarian regions ranged between 68.6 and 70 years for men and between 75.8 and 77.3 years for women, which is significantly lower than the EU 27 average of 75.8 (men) and 82 (women).

In terms of overall development, Bulgarian regions scored between 21 and 39.2 out of 100 in the EU version of the UN’s Human Development Index (HDI)[2]; this is well under the EU 27 average of 62. This index is based healthy life expectancy, household income, and educational attainment levels.

According to data from the National Statistical Institute (NSI)[3], the population of Bulgaria at the end of 2007 was 7,640,238. This population is mostly urban (70.7%) and ageing, with recent growth in the age 60+ group. Population ageing is particularly acute in rural areas where 32.9% of the people are over 60 years of age.[4] The ageing population, decreasing fertility, increased mortality and a rise in external migration have led to a decrease in population in recent decades. This has in turn had negative impacts on the country’s main demographic and social structures and an inevitable impact on population health overall.



Policy and institutional overview

Cohesion Policy

The planning of Structural Funds use in Bulgaria is based upon a National Strategic Reference Framework (NSRF) 2007-2013 (Национална стратегическа референтна рамка (HCPP) 2007-2013). The NSRF’s main targets refer to high and sustainable economic growth, raising the competitiveness of the economy, developing human capital, and ensuring higher employment and income as well as better social integration. The NSRF is prepared on the basis of regional development plans, which were approved by the respective six Regional Development Councils (RDCs). District development strategies and municipal development plans are strategic documents at NUTS III and NUTS IV level respectively.

Total allocated Cohesion Policy funding for Bulgaria is broken down as follows: €3.205 billion from the European Regional Development Fund (ERDF), €1.185 billion from the European Social Fund (ESF) and €2.283 billion from the Cohesion Fund (CF). Structural Fund interventions for Bulgaria for 2007-2013 are set out in seven separate Operational Programmes (OPs). Five are funded by the ERDF including Competitiveness, Environment, Regional development, Technical assistance and Transport; larger investments in the environment and transport sectors are also funded by the CF. Two OPs, Human resource development and Administrative capacity, are supported by the ESF. The focus of this case study is on the OP for Regional Development (OPRD), which covers a broad range of investment priorities targeting specific development concerns in Bulgaria’s six convergence regions.

Managing Institutions

The Directorate General “Programming of Regional Development” within the Ministry of Regional Development and Public Works is the Managing Authority (MA) of the OPRD. The MA is comprised of several different departments:  Programming and Monitoring, Implementation of Programme Priorities, Financial Management and Control, Legislation, Risk Assessment and Irregularities.

The MA also includes six regional departments, which are part of the ministry and directly sub-ordinate to the Director of the Managing Authority. The regional departments provide specific functions in the region on behalf of the MA, including ensuring information and publicity for the programmes; consultation and advice to project applicants; review and verification of applications and continuous project monitoring.

The Regional Development Councils, which represent the 28 administrative districts in Bulgaria, provide a more localised perspective. They submit opinions on the measures that should be implemented at the regional level with respect to the OPs; assist in the evaluation of a pipeline of projects for OPs; participate on Monitoring Committees through appointed representatives;interact with Municipalities and their Associations, District Development Councils and the central administration.

Health sector

Overview of institutions

The Ministry of Health (MH) is the main central government authority which is responsible for the overall management and control of the Health System. A system of regional health ministry structures has been in place since 1995. There are Regional Health Centres and inspectorates in each of the 28 administrative districts of Bulgaria. The MH is the authorised national institution for the implementation of the NSRF for the health sector.

Healthcare in Bulgaria: Main Figures

Health spending as percentage of GDP on healthcare, estimated at 6.9% in 2009

Health Establishments for hospital aid 352, including 306 hospitals and 46 dispensaries as of 2007

Hospital beds: 45,906 in hospitals and 4,135 in dispensaries as of 2007

Healthcare professionals: 48,099 as of 2007

Overview of public health policies and objectives

The National Health Strategy 2008 – 2013(Националназдравнастратегия2008 – 2013)developed by the Ministry of Health defines the objectives and the priorities of the health system. The strategic goals of the National Health Strategy 2007 – 2012 are:

1. Ensuring conditions for promotion of health and prevention of diseases

2. Providing guaranteed healthcare services with increased quality and ensure access to them

3. Improving outpatient medical care

4. Restructuring and efficient management of hospital healthcare

5. Ensuring of medicines and medical products, matching the demands of the customers, and their economic abilities

6. Creating a system for human resources development in the healthcare industry

7. Creating an integrated healthcare electronic system

8. Ensuring fiscal sustainability of the national healthcare system

9. Effective membership in the European Union

The MH develops the National Health Programmes for improvement of the health status of the population and develops the legislative documents within the sphere of the health sector.



Health in the Structural Fund programmes

Direct funding for the health sector

The OPRD for Bulgaria mainly considers health in the context of direct investments in health infrastructure development and medical equipment supply. As stipulated in the NSRF, the OPRD will support the development of sustainable, close and approachable city centres, will provide the relevant and profitable healthcare infrastructure, through modernization of the infrastructure and the equipment of the healthcare institutions for primary, emergency, specialised outpatient and hospital aid.

Direct spending on healthcare is envisioned within Priority Axis 1 and 4. Similar projects are covered under both axes, but Axis 4 targets smaller municipalities located far from bigger agglomerations. The major health issues the programme targets include emergency medical care, delivery of medical care in hospitals, specialized outpatient and in-patient care.

Direct funding for health is also provided for in the OP Human Resources (health - institutional strengthening, productivity through better health services) and the OP Administrative Capacity (e-health).

Non-health investments

While the discussion of non-health investments in the OPRD does not directly refer to health gains, it does consider social health determinants, such as the improvement of social inclusion and equal opportunities for disadvantaged communities, and better accessibility to health care through improvements in transportation networks.

Integration of vulnerable groups into employment, education, elimination of discrimination, healthcare, housing, and other sectors is given priority on the OPRD. The analysis also stresses the need to improve accessibility for the disabled in public buildings (including health care establishments), public transport and recreation facilities. And last but not least, minimising the potential risks for the environment and human health is of utmost significance in every investment intervention supported within the OPRD.

Priority Axis 1: Sustainable and Integrated Urban Development lists among the key project selection criteria that the interventions should contribute to improvement of quality of life, living and working environment. Indicators of achievement for this priority are:  the number of students benefiting from improved educational infrastructure; patients benefitting from improved healthcare infrastructure; population benefitting from refurbished buildings (non health care buildings).

Priority Axis 1 also contains provisions for several measures aiming at improvement of living standards for the Roma population. These include support for access to health services, preventive health care, measures for preserving the Roma cultural identity and housing measures. The OPRD states that these measures are expected to have positive impact on public health.

The fourth operation of Priority Axis 1 aims at improvement of ‘Physical Environment and Risk Prevention’ and is dedicated to regeneration projects; e.g. public recreation areas, parks, playgrounds, cycle paths, pedestrian zones, alleys, access of people with disabilities to administrative buildings.

The fifth operation focuses on improvement of the environmental performance of transport investments, including investments buses and trolleys and road rehabilitation. This is expected to indirectly contribute to improved accessibility to health by improving connectivity to health centres as well as equal opportunity and access to transport for disabled people. These interventions are also expected to bring reductions in environmental pollution which will in turn benefit health.

Priority Axis 3: Sustainable Tourism Development also envisions the development of health tourism.

Priority Axis 4: Local development and co-operation. The specific assistance to be provided includes: the enhancement of opportunities for educational, health care and business services for the local communities by means of improving the related infrastructure as well as improvement of quality of environment and risk prevention. This axis funds small-scale operations and is designed for small municipalities and more remote urban agglomerations.

Tables 2 below summarises the key priorities and intervention areas of OPRD, as well as their correlation with the proposed briefing sheet topics. Whenever applicable, the table also shows how health is considered within each priority.

Tables 2: Overview of Bulgarian OPRD

OP Regional Development

MA: Ministry of Regional Development and Public Works

Total EU allocation: EUR 1.36bn

Priority Axis

Funds (€m)

Percent of total OP

Content of priority/Operations

Briefing Sheet topic(s)

Health considerations in the priority

Sustainable and Integrated Urban Development




1.1. Social Infrastructure

1.2. Housing

1.3: Organisation of Economic Activities

1.4. Improvement of Physical Environment and Risk Prevention

1.5. Sustainable Urban Transport Systems

Transport, Social infrastructure, Energy


Contribution to quality of life, living and working environment by benefiting from improved educational infrastructure, improved healthcare infrastructure. Social inclusion of disadvantaged people and equal opportunity: disabled  access to public buildings, or improved housing for vulnerable communities (e.g. Roma)

Regional and Local Accessibility




2.1. Regional and Local Road Infrastructure

2.2. ICT Network

2.3. Access to Sustainable and Efficient Energy Resources


Transport, Energy, ICT, Climate change and adaptation


Contribution to equal opportunities through improved access to health resources (e.g. additional population covered by broadband and roads network and improved  connectivity of disadvantaged population with urban centers

Sustainable Tourism Development



3.1. Enhancement of Tourism Attractions and Related Infrastructure

3.2. Regional Tourism Product Development and Marketing of Destinations

3.3. National Tourism Marketing

Culture and heritage

Possibility to invest in health tourism

Local development and cooperation




4.1. Small-scale Local Investments

4.2. Inter-regional Cooperation

Social infrastructure, Infrastructure: waste Institutional capacity, ICT

Enhancement of opportunities for access to educational, health care and business services for the local communities by means of improving the related infrastructure; Improvement of quality of environment and risk prevention.

Technical assistance




5.1. Management, Monitoring, Evaluation and Control

5.2. Communication, Information and Publicity

5.3. Capacity building of OPRD beneficiaries

Institutional capacity



Integrating health in the programmes

This section discusses the process and approaches in integrating public health issues into the planning of the OPRD. It is based mainly on interviews with managers and experts in the OP Managing Authority and health experts. A list of interviews conducted is contained in the References section of this report.

The National Health Strategy (2008-2013) puts forward the policy goal of integrating "Health in all policies" which includes the impact of all policies outside the health sector on public health. This cross-sectoral cooperation is to be achieved by political decision-making, implementation of strategic planning and practical implementation of interventions. The ultimate goal is to facilitate the development of policies based on scientific evidence, including assessment, comparing health determinants and outcomes of health status.

With regard to integrating health gains in non-health investments under the OPRD, officials from the Managing Authority largely agreed that health gains are mainly implicitly considered through the environmental, economic, educational and other aspects of the programme and the policies and strategies on which it is based. In other words they are not specifically recognised, measured or optimised within the programme content or implementation, but the programmes nevertheless clearly contribute to health gains.

Ivan Popov (IP) stated that the OPRD is designed to ensure environmentally friendly investments which in turn contribute to better living conditions of the population, e.g. rehabilitation projects are granted extra points if they employ alternative renewable energy sources. He stated that health gains are clearly taken into account within the priority axis funding health infrastructure and equipment, but also in other priorities touching upon wider economic, social and environmental determinants of health.

Dessislava Yordanova (DY) noted all schemes encompass measures that work towards ensuring a healthier way of living of the population overall. Therefore it is implied that public health as suchis considered at horizontal policy level even if not directly stated. Maria Stanevska (MS) described this point further, stating that the OPRD is designed to ensure sustainable development of the agglomerations (cities, towns, rural areas) towards overall improvement of quality of life. Considering the above health aspects are built into the concept of sustainable development, they are thus well integrated in the OPRD. Additionally IP noted that the OPRD considers all relevant Bulgarian legislation which sets the standards and minimum requirements for implementation of certain activities. These standards include public and human health aspects.

Consequently, all interviewees agreed that currently health impacts are accounted for through other non-health indicators (environment, social, education, sustainable development etc.), since health indicators as such are not foreseen in the OPs for non health investments. Health aspects are considered at the stage of project proposal and selection process but, again, mostly indirectly. For instance, the reconstruction of a playground should follow strict requirements and detailed standards for the installations, defined for health and safety reasons in existing legislation. All project proposals should include a justification of the proposed intervention. An application is positively assessed and is granted additional points if it comprehensively presents the project’s contribution to sustainable development goals.

The future programming period

MS stated that the process of the elaboration of the new OP for the period 2014-2020 has been initiated, and that the SWOT analysis has already been commissioned. The OP will consider the goals and objectives of the Europe 2020 strategy. It is not anticipated that the approach to health issues will differ from the current one. There is no concrete plan at this point on improving the current practice towards public health considerations for the upcoming programming period.  All existing EU and Bulgarian legislation and policy documents will be consulted during its development. DY expressed the concern that - in the context of Bulgaria – a legal requirement or at least a guidance recommendation would have to exist to ensure more direct, concrete integration of public health aspects into programmes. If emphasis should be placed on outlining the health gains of non-health investments in the upcoming programming period, relevant instructions should be communicated to the MAs by the European Commission. Consequently a clear set of indicators should be developed to allow the setting of targets and the measuring of achievements and results. IP added that OP schemes could then be promoted in the future through their expected health gains.

Speaking from the health authorities’ perspective, Lidia Georgieva (LG) noted that it would be important to carry out research devoted to correlating non-health investments with health indicators, as this would be a necessary to ensure an evidence-based assessment of health gains from non-health SF investments.

Consultation with health sector in the 2007-2013 programmes

Drafting the OPRD for the period 2007-2013 was entrusted to a working group under the responsibility of the MRDPW. This working group started developing the programme in October 2004, with wide participation and representation of over 40 stakeholders representing various institutions both at national and regional levels, i.e. managing authorities, line ministries, state agencies, Regional Development Councils, associations of municipalities, regional development agencies, business and the employers’ associations, syndicates, NGOs and other relevant parties.

It was communicated during the interviews that the OPRDunderwent numerous amendments to reflect the dynamic changes of the relevant conditions. Thussome 13 drafts were discussed at wide consultation forums with the participation of representatives of all stakeholders. Targeted conferences were organised to ensure broader public participation in the development of the programs – for example the 10th version of OPRD (Priority 3 Sustainable Tourism Development) was presented for consultation during a conference “Tourism in Central Balkan at the eve of EU accession”

MS confirmed that the development of the program was in line with the requirements of the EC. In fact all stakeholders were properly involved and their input was taken into account during the programming period. Furthermore the inter-institutional cooperation in the process of elaboration of the program was assessed as satisfactory, despite the lack of a concrete coordination procedure. The MH had representatives at all meetings of the working group and provided opinion on the whole operation program including the direct health investments and non-health infrastructure interventions.

Role of the health sector

Health authorities were formally involved as members of the working groups consulted in the development of the programmes as described above.

IP stated that during the implementation of the OPRD, cooperation between institutions is usually between experts, rather than at higher political levels. Representatives of the health ministry are on the programme monitoring committee, take part in relevant written procedures and ad hoc decisions, and are consulted by the MA for specific opinions or positions on relevant topics. The health ministry is not formally involved in ex-ante or ex-post evaluations of the program.

It was noted by the experts that the health institutions do possess capacity to provide input to the development and implementation of the OPRD, but this capacity is still being tested. Implementation of the health care infrastructure scheme as part of the OPRD has only recently begun in earnest (first contracts signed in February 2011) and the capacity of the health ministry to carry out these investments is still to be seen.

According to Lidia Georgieva (LG) the health ministry does not formally consider the health aspects of non-health investments projects. One weakness she mentioned was that the ministry does not have management responsibility beyond the programmes that directly finance health investment.

Further needs

Interviewees agreed that OPs could benefit from better reflection on the actual and potential health gains of Structural Fund investments. It will be crucial to include health considerations in ex-ante and ex-post assessments. The idea that health gains could be stated as a clear value-added of the programmes and be used in their promotion was also raised.

Interviewees stressed that the MA should be always informed and updated on trends, policies and practices relevant to health, and that the dialogue between MAs, civil society and other stakeholders can be strengthened. It was agreed that there is a need for better understanding and a systematic approach to properly reflecting the impact of non-health investment on public health.

Finally, interviewees stressed that the EC legislation, policy and guidance should give clear indications and guidanceon issues which should be included in OPs including the public health gains.  




Национална здравна стратегия 2008 - 2013г. и План за действие към нея, 16 Декември 2008г. National Health Strategy 2008-2013 and Action plan (16 December 2008).

Национална стратегическа референтна рамка (HCPP) 2007-2013, National Strategic Reference Framework (NSRF) 2007-2013)

Националнастратегия за регионално развитие на Република България за периода 2005 - 2015г. National Regional Development Strategy for the period 2005 – 2015 (NRDS)

Национална оперативна програма “Регионално развитие” 2007-2013 г.,  Operational Programme “Regional Development” (OPRD) 2007-2013


Interviews with health experts:

Ms Lidia Georgieva, MD, МPhill, PhD, Department "Social Medicine and Health Management"  Medical University – Sofia, Bulgaria, Former Director of Directorate Management of Projects and Programs, Currently Adviser at the Ministry of Health. The interview took place on April 18. 

Interviews with the Managing Authority for OPRD:

Directorate General “Programming of Regional Development” within the Ministry of Regional Development and Public Works (MRDPW)

Ms Maria Stanevska - Head of Department "Implementation of Programme Priorities"

Ms Desislava Yordanova - State expert in Department "Implementation of Programme Priorities"

Mr Ivan Popov - acting Head of Department "Programming and Evaluation"

All interviews were carried out during the period 18-22 April 2011.

[1]However for consistency purposes and with relevance to Fifth Cohesion report data the population in 2007 was7.65million and this number is taken into account in this report for statistical and comparison purposes.

[3]Health, Statistical Brief Guide for 2007, issued by the National Centre for Health Information, Sofia, 2008) Source: