Bulgaria A Country Report

8/6/2019 Bulgaria A Country Report

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CONTENTS

Acknowledgements

Introduction

Profile of Bulgaria

Legislation

Care and Service Provision

Dynamics within the NGO Sector

NGO Activity in the Field of Mental Health

Other Agencies

In Conclusion

Appendix 1- Public Health Act (1973)

Appendix II - Rules for Application of the Public Health Act

Appendix III - Constitution of Republic of Bulgaria

Appendix IV - Schedule of Visits and Meetings

Appendix V - References




ACKNOWLEDGMENTS

In writing this report I am reminded afresh of the kindness, the patience, thegenerosity and the hospitality with which I was received when I visited Bulgariaearlier this year. I feel privileged to have met with and, to some little extent, tohave shared the experiences of a number of remarkable people during that visit. Iwish to express my thanks and my admiration to all those who welcomed me andwho made this report possible by readily and willingly finding the time to meetwith me. Without this support my task would have been considerably moreonerous and much less enjoyable.

In addition to those who met with me on a professional basis, I wish to extend mythanks to everyone who allowed me to share in a little part of their life. In

particular my thanks go to the service users who took the risk to meet with meand answer my questions and to the families of Raina Vladimirova, EmiliaDimitrova and Amelia Nikolova who so warmly welcomed me into their homes. Iam also indebted to Alia Veder for all her efforts on my behalf regarding thearranging of meetings, accommodation, transport etc.




INTRODUCTION

I visited Bulgaria at the end of February 1998 in my capacity as Research &

Development Officer with InterMinds. This visit followed on from a visit made to Sofiain July 1997 by Peter Kampman, the Chief Executive of InterMinds. There has beencontinued contact with Bulgaria since then, mainly through the Neuroscience andBehaviour Foundation, and increased interest in the possibility of assistance fromInterMinds. However it became clear that, before committing the organisation, weneeded greater clarity about the real situation of mental health in Bulgaria.My remit was to form an overview of mental health care and service provision inBulgaria and, more specifically, to establish as clear and accurate a picture as possibleof the non-governmental sector working in Bulgaria in the field of mental health. To thisend I met with a number of people in senior positions working with NGOs from Sofia,the capital of Bulgaria, and from Targovishte and Shumen, two smaller towns in the

west of Bulgaria. I also had the opportunity to meet with service users in Targovishte,in-patients and outpatients at Shumen Psychiatric Unit, staff from the Centre of Hygiene in Sofia and the Chief Advisor to the Minister of Social Affairs withresponsibility for NGO liaison. Furthermore I visited the Psychiatric Unit attached toShumen Hospital and psychiatric wards within Targovishte Hospital.

With regard to forming a clear picture of the NGO sector in Bulgaria, I focused myattentions on the following areas:

• Identifying both national and local organisations working in the field of mentalhealth by means of meeting with representatives from these organisations.

• Clarifying the areas of interest of the various NGOs.

• Researching specific activities, both actual and proposed. Finding out whatprojects are up and running and how they are developing. Looking at proposalsfor projects and what is needed to implement them.

• Requesting information about the NGOs themselves: how they were established,how they are structured, what resources they have, how they are funded, whatstaffing they have etc.

• Exploring as far as possible what differences exist between NGO activity in Sofia

and in rural areas.

• Remaining open to the culture of the country.

• Exploring the relationships between NGOs, whether they work together and if so, how they work together.

• Collecting information regarding other international involvement and presence inthis field.

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One week is a relatively short period in which to collect and explore the informationnecessary to give an accurate picture of NGO activity in the field of mental health inBulgaria. I did however leave with some fairly clear impressions, thanks largely to the

wonderful energy, willingness and enthusiasm of many of the people with whom I met.Most of those people were juggling full time and demanding jobs along with family and,what often appeared to be an almost full time commitment to their NGO involvement.

And yet they readily and willingly fitted in extensive meetings with me and took the timeand trouble often to come prepared with information and details about their work andprojects or to ensure that this was passed on to me later.

The following points will give some idea of what my research identified, with fuller details being provided further on in this report.

Bulgaria is currently struggling to emerge from a survivalist culture, which

predominated of necessity during the Communist regime, and to move on to a culturefocusing on development. There is growing awareness in certain areas of thepopulation that, as change is inevitable, now is the time to take some control of thatchange in order to establish and develop policies, services, resources which will be of benefit to the country and the community.

Despite the deprivations and hardships of the past twenty odd years, and against abackground of depression and frustration, there are indications of an impressive energyand motivation in certain areas. This is particularly apparent in the attention that isdirected in some families at encouraging and supporting children to make the most of available opportunities in the area of education. Schools appear to adopt a shift systemwhereby the school remains open from 7.00 hours through until 19.00 hours, withpupils attending in two shifts. Many children use the time out of school to followspecialist areas such as music, languages, and sport. This valuing of educationalresources does not however seem to be reflected in the status or salaries of theteaching staff. Sadly, this contrasts vividly with the lack of opportunities for marginalised groups such as the Roma population, whose children are more often outof school than in attendance.

There is a growing belief among some people however that this seemingly supportiveattitude of parents is evidence of the culture of paternalism that has been prevalent inBulgaria over centuries. As such it hinders and disables rather than empowering andenabling those whom it purports to assist. Paternalism and patriarchy perpetuate a

climate of helplessness in the face of control and power.

Alongside the above-mentioned energy and motivation to develop amongst somepeople, there is a strong feeling of frustration at the lack of the guidance and directionto which the country as a whole has been accustomed for so long. Where there wasonce paralysing control, there is now nothing. The new government is concentrating itsenergies on developing appropriate policies and legislation but this of course takestime. In the meantime the people have for so long been used to being “taken care of”,that it is hard to begin to take responsibility again. So there is almost a feeling of

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vacuum and nothing happening. Unemployment figures are high and there is littleaccessible support from the state for people in need. Suicide figures quoted fromresearch done by an NGO in Sofia suggest that in 1997 about 1400 people commitsuicide every year with the number of attempts figuring between 5 and 10 times more

(see “Budnina” Foundation).

In the area of mental health, there is no existing specific legislation although theMinistry of Health is currently exploring and discussing the, for Bulgaria, new conceptof Mental Health Reform. Equally there are no mental health policies in action.However a number of key individuals working in the field of mental health haveapparently been asked to address the need to develop relevant policies. With regard tointroducing the concept of community care, there are obvious difficulties due to the stillenormous stigma connected with mental health issues, in addition to strong oppositionfrom older psychiatrists who wish to perpetuate the existing, traditional hospital basedsystem of care. However there is a feeling of optimism about support from the present

Government in this area.

In Bulgarian culture there is no history or experience of user or carer initiatives. Thevery idea of a patient being in any way active in his/her own life as a user of services isstill very new. There is very little continuity of care at a professional level, sorelationships are not built between the patient and professionals and the controlremains firmly in the hands of the professional who is currently involved.

There are some NGOs working in the field of mental health in Bulgaria, with varyingdegrees of success and activity. There is awareness amongst most of the groups withwhich I met, of the importance of networking and pooling resources. At the same timethere is an atmosphere, especially in Sofia, of mistrust and possibly jealousy betweensome of the NGOs regarding the securing of outside support and funding. There is noeffective national association or organisation as yet. I shall provide details in this reportof the specific areas of activity in which some of the existing NGOs are involved and of a number of project proposals. I also had the opportunity to visit a psychiatric unitattached to one of the regional hospitals at Sumen near the Black Sea, to meet withusers who are actively involved in the work of an NGO based at Targovishte and tomeet with Department Heads at the Centre of Hygiene in Sofia.

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PROFILE OF BULGARIA

The Republic of Bulgaria is situated in the south eastern part of the Balkan Peninsula.With a population of 8.4 million, Bulgaria covers an area of approximately 111,000square kilometres. To the south Bulgaria shares borders with Turkey and Greece andto the west one finds Serbia and the Republic of Macedonia. Romania lies to the north,separated from Bulgaria by the river Danube and the Black Sea forms a natural eastern

border. The fifteenth largest country in Europe, Bulgaria lies at the centre of a regionthat is in the process of dynamic change and development. Since 1989, the country hasundergone a series of rapid and at times turbulent political changes.

Historically Bulgaria has experienced a number of influences over the years from other cultures. Following the invasion of the Bulgars in the 7th century AD and their gradualadoption of the culture and language of the conquered Slavs, Bulgaria became asignificant power in South East Europe. Despite coming under Turkish rule in 1396, theBulgars succeeded in retaining their national identity over the centuries until they onceagain became independent in 1908 under the Saxe-Coburg ruler Ferdinand, who tookthe title of tsar. He however was forced to abdicate in 1918 after supporting the CentralPowers. Bulgaria aligned itself with Germany in both World Wars. In 1944 it wasoccupied by the Soviet Union and power was seized by the Fatherland Front, a left-wing alliance, which formed a pro-Soviet government that declared war on Germany. In1946 a People’s Republic was proclaimed and Bulgaria became one of the SovietUnion’s satellite states. Under a new constitution in 1971 Todor Zhivkov became headof state until pressure for reform forced him to resign in 1989. Democratic multipartyelections were held in 1990, resulting in victory for the former Communists, now styledSocialists. Further elections in 1991 resulted in victory for an anti-Communist coalitionled by Filip Dimitrov; a broader coalition took over in 1992. In 1994 the Socialists werere-elected and Zhan Videnov became prime minister. A non-socialist president, Peter Stoyanov, was elected in 1996. In 1996-97 economic crisis led to mass protestsagainst the Socialist government. Parliamentary elections held in 1997 were won by a

centre-right coalition led by Ivan Kostov.

As a parliamentary republic, Bulgaria is governed by a one-chamber parliament calledthe National Assembly to which elections take place every four years. The President isthe head of state and is assisted by the Council of Ministers, an administrative bodythat directs the domestic and foreign policy of the country. For the purposes of administration, the Republic of Bulgaria is divided into 278 municipalities and 9regions. The municipality is a legal entity and has the right of ownership and anindependent municipal budget. The municipal council is the local government authorityin the municipality and determines the policy for the construction and development of the municipality. The regions are administrative-territorial units for carrying out regional

policy and implementing state government. The region’s management is effected by aregional governor and regional administration and their maintenance costs are paid bythe state budget. The regional governor is appointed by the Council of Ministers andthe deputy regional governor by the Prime Minister.

In 1991 Bulgaria chose the path of rapid and radical economic reform, joining theInternational Monetary Fund and beginning the process of adapting to a marketeconomy. Privatisation began in Bulgaria in 1993 with an ambitious mass privatisationprogramme being adopted by the government in 1996. With regard to foreigninvestment, Germany, the Netherlands and then the UK are the three largest investors



in Bulgaria. Foreign investment is important evidence of Bulgaria’s determined movetowards European integration of which the first step was the signing in April 1993 of theEurope Association Agreement. This Agreement came into force in February 1995 andcontains intentions and resolutions regarding different aspects of the political,economic, social and cultural integration of Bulgaria into the structures of the EuropeanUnion. This document also highlights the breakdown of trade barriers and includes theintention to move towards the harmonisation of EU and Bulgarian legislation.

Due to the recent economic crisis in Bulgaria and the ongoing restructuring of theeconomy in the last few years, the labour force has been strongly affected.Unemployment is high with the rural areas being worst hit, as there are fewer opportunities for jobs. Areas such as Sofia, Plovdiv and Varna are slightly better off.For a country such as Bulgaria where investing in education and training has been anational characteristic for hundreds of years, unemployment is especially demoralising.People of all ages readily make personal and financial sacrifices in order to study, withparents supporting and encouraging their children even during the recent difficultyears. The majority of Bulgarians speak at least one foreign language. Until recently alleducated people spoke fluent Russian although now the preferred language is English.French is also common. In most of the major cities there are foreign language schools,both primary and secondary, state and more recently private, where most subjects aretaught in a selected foreign language. However the sad reality today is that a goodeducation no longer ensures you a job.

Bulgaria does adhere to a policy of a minimum monthly wage that is subject to regular changes by the government according to the rate of inflation. Some employmentconditions are, by western standards, fairly progressive. For example maternity leaveentitlement for a first child is 120 days plus paid leave until the child reaches the age of 2 years so that the mother can be directly involved in raising her child at home. Publicsocial security, (social security tax is obligatory for both employers and employees),also covers paid leave in order to take care of a sick child or family member. Despite

these provisions, many couples make a conscious decision to have only one child inorder to be sure of being able to support their family in the current economic climate. Imet a number of women during my visit to Bulgaria, and heard of others, who had leftthe decision to have even one child too late, due to a very real fear of poverty. Thefamily unit still plays an important part in Bulgarian culture although divorce and singleparent families are becoming increasingly common here as elsewhere in Europe andthe west.



LEGISLATION

There is an urgent need for change in legislation in Bulgaria as at present there is nospecific legislation concerning mental health or psychiatry. The immediate need andfirst step, as seen by concerned professionals working in the field of mental health, is tosensitise the government to the need for change and to then assist in preparing thegovernment for this change. The current General Health Act, which was passed in1973, contains one paragraph relating to the involuntary treatment of patients (see

Appendix I, Article 36). Another section deals in more detail with compulsory measuresfor offenders with mental illness who are therefore considered incompetent (see

Appendix I, Articles 59-67). Special regulations regarding custodial measures for thementally ill are outlined in the General Health Act. Where a mentally ill person is alegal offender, the provisions of the Penal Code of 1968 are complied with. Althoughdifferent texts are available, including information from abroad, the criteria for assessment of legal incompetence lack clarity. Up until now there have been no

mental health policies but the Ministry of Health is currently discussing new concepts of Mental Health Reforms and have asked a number of key workers in the field to addressthe need for policy making. Dr Toma Tomov is one of the professionals who has been,and continues to be, instrumental in the preparation of a new programme of reform for psychiatric care in Bulgaria. Dr Tomov is the Head of the Department of Psychiatry atthe University Hospital Alexandrovska in Sofia, a member of the WHO Expert Panel inMental Health and an advisor to the United Nations for Mental Health Programme. Heis also the elected President of the Association of Mental Health Reformers in EasternEurope that is to be based in Sofia.

Over the past 25 years, various texts and documents have been prepared regarding

psychiatry and mental health in Bulgaria and including some comparative studiesbased on a number of other countries. Some of the more recent studies have beentranslated into English. However there has been no change in legislation since the1970s. Existing legislation closely resembles the traditional legislation in a number of other countries of Eastern Europe. This is beginning to change elsewhere but there isthe feeling that Bulgaria is being left behind. Now, with increasing pressure from theCouncil of Europe, the State will have to implement changes.

Apparently there are now many organisations and individuals in Bulgaria with aninterest in mental health issues. However only a few are active due mainly to post-communist problems, lack of funding and lack of motivation. There is some recognitionthat the lack of money is, at present, of secondary importance and that the major

difficulty is to change the prevailing attitudes and to move on from a survivalist cultureto one of development. In recent years, most psychiatrists for example, directed their efforts and energy towards ensuring their own survival by means of securing animmediate income. In 1990, on the initiative of the Minister of Health, a group of fiveprofessionals involved in the field of psychiatry and mental health began to work on aproject to prepare a draft for a new Mental Health Act. The draft, which has beentranslated into English, was at the stage of being presented but was withdrawn by thegovernment. Of the working group, only three members were actively involved alongwith some input and assistance from the Geneva Initiative on Psychiatry. Now only onemember remains actively involved with the aims of the project. As the president of the





mental health difficulty is the same as in the Penal Act.

The draft for legislative reform also makes reference to the issue of Guardianship. Thisdoes exist in Bulgaria for people who are considered to be “totally mentallyincompetent”. There is a chapter of the draft proposal regarding temporaryguardianship for people who need representation because of mental health difficultiesthat are temporary and short term.

NGO Influence on Legislation

In Bulgaria, there has been little official recognition of non-governmental organisations(NGOs) and therefore no consultation with them. No-one asks NGOs for their opinionsor that they share their information and experience. Professionals and specialists willbe invited to give their opinions but NGOs find it very difficult to influence anylegislation, as they are not consulted. There is a growing belief now that there is a need

for some body to be established in order to ensure contact and communicationbetween NGOs and government agencies. There are currently moves in Sofia, initiatedby an emergent mental health NGO, to establish a Consultative Council for thispurpose. It is hoped that any mental health legislation may be passed through thisCouncil. There was the feeling when I spoke with people earlier in 1998, that action inthis area was urgently needed, as there was a package of social legislation about to bepassed, part of which would relate specifically to mental health. This is certainly seenas progress since previously there has only been legislation relating to general health.

Consultative Council

The principal promoter behind the idea of a Consultative Council is the initiator of aNational Association of NGOs. Rumen Ratchev hopes to establish a national forum of NGOs, with one branch focusing on mental health, which will enable co-operation andwill strengthen the position of NGOs in general. There are approximately ten NGOsactively interested in the aims of a National Association. One of these aims is to createa Consultative Council.

The following paragraph describes the proposed system for building a ConsultativeCouncil.

A working group will be established, starting with representatives from those NGOs

already interested in the aims of the National Association and possibly also involvingrepresentatives from some government agencies. This group will look at legislation thatis already in existence e.g. social laws and will aim to promote the interests of NGOswith regard to legislation. Through the Council, legislation can be discussed andsuggestions for amendments or changes can be proposed and passed to the relevantgovernment body. At a later date representatives will be invited from NGOs to sit on theConsultative Council itself. Rumen Ratchev believes that such a Council could succeedif it is established now in the current political climate that is more democratic withregard to the establishing of a civil society.



Government Attitude towards NGOs

I had the opportunity, while in Sofia, to meet with Mario Sarbinov, the newly appointedChief Advisor to the Minister of Social Affairs who has particular responsibility for co-ordinating meetings and liaising between NGOs and the Ministry. This is a very recentpost, set up in July 1997, which has been specifically created in order to facilitateinteraction between the government and the NGO sector. Mr Sarbinov informed me thatthe Government is now actively engaged on a programme of developing legislation withthe recognition that it must then address the need to form and implement realistic andeffective policies. According to Mario Sarbinov there are a number of charities andNGOs across Bulgaria that are involved in providing humanitarian aid mainly for vulnerable groups such as children and the elderly. They exist primarily to distributesome aid and to encourage international agencies to send aid. Such organisations aremore active and developed in Sofia than across the rest of Bulgaria. However NGOsare limited at present as there is no specific law relating to their activities. There is a

book that is in the process of being printed which will give details of different legislativeacts in existence that can assist NGOs in their work.

Mr Sarbinov spoke also of a Consultative Council of NGOs which is currently beingestablished in order to influence policy. I am unclear as to whether or not this is thesame consultative body as that which Rumen Ratchev is involved in establishing. ThisCouncil began to be formed at the beginning of 1997 to assist in the short term with thedistribution of humanitarian aid. Now the idea is to develop this body so that it mighteffectively assist with legislative reform. Often such groups are formed with no clear idea of their actual remit and with little concept of how to collaborate with localgovernment. Also there has been a tendency to involve people from within the state

system who are neither popular choices nor appropriate, as they usually have norelevant experience. The system for establishing consultative councils was there butthe practice of implementation was not good. There is good reason to hope that, withthis awareness and with the creation of posts such as that of a Chief Advisor withspecific responsibility to work with NGOs, the situation will improve.



CARE AND SERVICE PROVISION

Health reform is beginning in Bulgaria. The intention is to establish a service similar tothat in the UK with one central state fund and then a system of local generalpractitioners. As yet though the central health fund has not been collected and there isno provision within the existing system of health care for psychosocial care. Under theproposed new system a psychiatric patient would be referred by his/her GP to aconsultant psychiatrist and then be sent back to the GP for care. If a patient is notreferred by a GP then he/she has to pay the hospital for treatment. Similarly if there isno direct hospital referral for specialist care or treatment then the individual needs topay also for this service. Sometimes this means that people pay three times for necessary care, firstly through social insurance, secondly to the hospital and thirdly toa specialist practitioner.

There is no real follow up or continuity of care at present. Most patients do not have

their own key psychiatrist but usually see a number of different people. Attempts arebeing made to change this by identifying one doctor to build a relationship with apatient and then to co-ordinate any necessary care. However GPs are not sufficientlytrained as they receive only six months of psychiatric training covering a series of eightexercises. Many qualified psychiatrists only in fact receive biological training with noopportunity for alternative training. There are very few alternatives available to thetraditional hospital based care. I visited one NGO (Bulgarian Brief Therapists Society),which has established a Day Centre Service at Sofia Hospital. The Centre useshospital premises although it is an NGO but there is ongoing conflict because theCentre tries to use less drugs and to work with alternatives to traditional psychiatry andthe hospital tries to insist on the use of drugs. Also people are afraid to use the Day

Centre Service as this involves coming to hospital premises; they would prefer to seethe therapists elsewhere. Many attempts are being made by this NGO and others tofind funding to provide alternatives to psychiatry as a means of managing mentalillness.

There is a growing recognition amongst mental health NGOs of the importance andneed for community-based initiatives to provide alternative care and services to theexisting hospital based system. At present psychiatric care continues to be dispensedby psychiatric hospitals, clinics attached to university medical departments,dispensaries, and health centres, specialist annexes attached to general hospitals.There is now a more optimistic feeling about the possibility of support from the presentgovernment and NGOs are trying to introduce a concept of care where community care

plays a valued part. There is still however strong opposition from the older moretraditional psychiatrists who wish to perpetuate the existing hospital based system of care. The number of hospital beds has been reduced for both short and long staypatients, probably for economic reasons. This has inevitably caused concern amongsthospital staff regarding the likely loss of jobs. There might be the possibility for redundant staff to work on community projects if funding can be found. The economicpicture in Bulgaria has undergone a number of drastic changes in recent years andwhere, prior to 1989, professionals like doctors and lawyers were amongst the mosthighly paid now they are not. A qualified doctor or psychiatrist now earns on average100,000 leva per month, approximately £33.00. In comparison a retirement pension is



approximately 50,000 leva per month and a prescription costs 44,000 leva. There is nospecific training for psychiatric nurses in Bulgaria although there are some incidentalcourses. Up until five years ago, there were no clinical social workers in Bulgaria. TheUniversity of Sofia does now however provide specialist psychiatric training for socialworkers. There are though large gaps in existing training both for social workers andpsychiatrists. Patient’s rights and the concept of an interdisciplinary approach to careare only just beginning to develop in Bulgaria. Such aspects are missing from existingtraining. WHO compiled a database in 1994 that seeks to compare psychiatric careand service provision in Europe over the ten years from 1982 to 1992. Statisticalinformation, provided in the data-base, referring to the ratio of psychiatric staff (psychiatrists and psychiatric nurses) to heads of population, indicates a considerabledifference between the levels of human resources allocated to the area of mentalhealth in Bulgaria (and other countries of Central and Eastern Europe) compared withcountries in Northern Europe. Some doubts have been expressed as to the accuracyof some of the figures and the picture that they form. However, it appears clear thatthere has been little increase in recent years in the level of staffing working in the field

of mental health in Bulgaria.

From what I could determine, it is very rare for any needs assessment to take placeprior to care being recommended. I spoke to two psychiatrists in Shumen who said thatthey were not aware of any studies or surveys being carried out in order to evaluatewhether or not the services provided are in fact relevant to the needs of the serviceusers. Hospitals are regional and cover perhaps one hundred municipalities. Thehospitals, along with the care provided in the community by the local municipality, arefunded under a government-managed budget. However, given that there appears to beno clear relationship between the hospitals and community care, or what is known asmunicipality care in Bulgaria, it is very difficult for patients to leave hospital and move

into the community. Many professionals to whom I spoke feel that the state has a clear responsibility to provide patients with appropriate care but that this responsibility is notbeing met under the current system.

Existing Services

As there is no specific mental health legislation, equally there are no relevant or effective policies for ensuring appropriate care or support for people with mental healthdifficulties. There is little or no evidence of any needs assessments being carried outnor of any surveys or studies to determine whether or not existing services are relevantto the needs of those receiving them. Social Care Homes exist for certain groups of

vulnerable people i.e. the elderly, those with dementia, the physically ill, children withlearning difficulties. Support or care is provided by carers and paid for by the state.Some of the carers have special training though most do not. A training school hasapparently now been established in north-west Bulgaria to provide training for socialcare workers. Social Care Homes are the responsibility of the Social Work or SocialWelfare departments but there is no provision within this system for people with mentalillness.Under the communist regime, everyone had the right to work if they could and it wasthe government’s responsibility to find appropriate work (see Appendix III, Article 48.1).This is no longer the law, although many people want this to change. There used to be



co-operatives where invalids and mentally ill people lived and worked together (see Appendix II, Part 5: Work Therapy). Such places no longer exist. With no real socialpolicy in place there is a very high rate of unemployment throughout the country, evenfor those without any difficulty. The government apparently does not support thepossibility of supported accommodation projects. Any money given for such projects isliable for tax so it becomes too expensive for such projects to exist.

I heard of some support centres, established and run by NGOs and focusing onspecific needs. However, although 100% of the funding required for these centres usedto be provided by the government, these centres now have to self-fund.

Hospitals

In Bulgaria in 1997 there were 15 psychiatric hospitals, accounting for 59% of allpsychiatric beds. No new hospitals have been opened since 1975. The hospitals

provide, on average, between 400 and 500 beds each, with Radnevo Psychiatrichospital being the largest such institution (620 beds). Only 2% of beds are reserved for patients experiencing senile dementia, although available data suggests that around9% is required in order to ensure adequate provision. The geographical distribution of psychiatric hospitals in Bulgaria is uneven. Hospitals are allocated according topopulation figures in each region rather than according to need. Some hospitalshowever accept patients from a number of regions. Thus in the region of Lovetch, thereare 4 hospitals providing 1785 beds, while in the region of Burgas there are nopsychiatric hospitals.

The conditions in hospitals and psychiatric units are very bad. I visited one hospital for

psychiatric patients and also one separate psychiatric unit. In addition I heard from anumber of patients and professionals about the conditions in other hospitals. From allreports there appears to be little difference to be found, regardless of whether thehospital is in a city or in a rural area. Priority in terms of resources and expenditurefrom allocated budgets appears to be given to general hospitals as opposed topsychiatric hospitals or units. Premises for psychiatric services are most oftentemporary and inappropriate, being adapted for example from old school buildings, aprison, a monastery etc but they soon become accepted as permanent.

The complaints were similar, focusing on not enough money, not enough food,insufficient medication, inadequate heating, insanitary washing and toilet facilities, littleor no laundry facilities etc. Meals are often inadequate and provide little nutritional

content causing patients to rely on friends and family to bring them something to eat.One example of a main meal described by a patient, consisted of a tomato with bread.In many hospitals the heating is only switched on in November, regardless of thetemperature. Heating is provided for two hours at a time and then turned off for twohours. As a result, patients complain that although they are perhaps receivingtreatment for their mental illness, they become physically ill because of the cold.

The psychiatric unit attached to Shumen General Hospital in the west of Bulgaria hasno heating, as there is not enough money. This unit is physically separated from themain hospital, thus, as continues to be the custom in many countries of Central and



Eastern Europe, perpetuating the tradition of segregation of the mentally ill from therest of the population. I visited this unit and found one nurse in attendance. The unithas approximately thirty beds, with four or five beds to a room, and one treatment roomthat serves also as the staff room. The day room, which is used for relaxation therapy,has damaged sofas, torn curtains and peeling paint and is hardly conducive torelaxation. Patients rely on their families to bring them in extra clothing to combat thecold and food, as the hospital diet is so poor. There are no sheets on the beds andusually only one or two blankets. Blankets are washed twice a year when possible,regardless of the number of patients using them. Patients go home at the weekendsand for public holidays where at all possible, in order to reduce expense. Patients andstaff use the toilets and washrooms in the unit alike. They are very basic andunpleasant smelling. I spoke with three patients at the unit, all of whom praised the staff for the care and kindness which they showed but criticised the lack of resources. Thenurse who showed us round the unit explained that she worked regular twelve-hour shifts. Although initially reluctant to let us into the unit, as she said that she would getinto trouble for admitting strangers, the nurse eventually agreed to show us round as

we were accompanied by two psychiatrists from a nearby town. Like most of her colleagues she has received no training although she would like to get some. What sheknows she has learnt on the job and by listening to the qualified staff.

I saw similar conditions to those described above when I visited the wards inTargovishte Psychiatric Hospital. This hospital has 80 beds of which 60 are for in-patients and the remaining 20 provide day-bed care. There are 6 doctors on the staff.

There is a feeling that in smaller towns, free medication is not available as thegovernment restricts it to the larger towns. As a result out patients in rural areas oftenhave to buy their own medication, as the hospitals do not have enough money to

provide the medication free of charge. Patients collect their prescriptions from thehospital clinic and then go to buy the medication before returning to the hospital for treatment. Sometimes patients do not return because they cannot afford to buy themedication. Medication is available but only if the individual can afford it. Often threeseparate items are needed for treatment, costing a total of 132,000 leva that is theequivalent to almost three months’ retirement pension.



DYNAMICS WITHIN THE NGO SECTOR

The principal reason for my visit to Bulgaria was, as described in the Introduction, toattempt to establish a clear view of the NGO sector. I was fortunate to have theopportunity to meet with representatives from a number of NGOs - a total of ten in fact -most of which are at different stages of development and activity. These meetings

provided me with a great deal of information about the internal structure of theseorganisations, who some of the key players are, projects both real and proposed,funding requirements, training needs and gaps in existing service provision. Details of the various NGOs, including some proposals for partnership working with PenumbraInternational, are provided as appendices. I also came away with the clear impressionthat people are no longer willing to sit back and accept the current situation with regardto mental health care. Furthermore I heard from a number of sources that there aregrowing numbers of individuals and organisations, patients, service users andprofessionals, who are becoming increasingly interested in actively influencinglegislation and policy development. There is also a heightened awareness of andinterest in the possibility of advocacy.

There was some considerable talk amongst the different NGOs of the recognised needand importance, for a number of reasons, for collaboration and cooperation. A number of stumbling blocks lie in the path of the development of the NGO sector in Bulgaria.Happily, as indicated in the following paragraphs, efforts are beginning to be made toremove some of these blocks.

As mentioned earlier, Bulgaria is one of many countries to be currently experiencingthe traumas of post-communism. For so long the culture in Bulgaria has been to waitfor the state to provide whatever the individual was entitled to and then to accept theinadequacies of that provision. There is no real experience of non-governmentalorganisations, volunteer initiatives or user bodies. Amongst users of mental health

services, the culture is still predominantly to wait for assistance from psychiatrists or other professionals rather than being able to act themselves to access possibleservices. There is a lack of confidence and a lack of information, both of which areaggravated by poor communication. In Shumen for example, out of 4,500 users of psychiatric services, only 35 use the services provided by the locally based NGOs.This is due partly to stigma and fear, partly to a lack of information and partly to lack of resources for the NGOs. The NGO sector needs to educate people about what istantamount to a new concept, that of a non-governmental resource which is available toeveryone and which its users can directly influence. In order to achieve this change inattitudes in a realistic way and within a realistic timescale, existing and emergent NGOsacknowledge that they must work together on a programme of education. Further to this

need to educate the public, there is also a need to educate and communicate with thegovernment. Again there is recognition that NGOs need to work together in order to beeffective in raising their profile at state level and in informing the government abouttheir potential, their areas of expertise and their needs. A united network of NGOswould certainly have more power as a possible consultative body with potential tocommunicate and cooperate with the government and to influence legislation andpolicy development in areas such as mental health.

Amongst the NGOs with which I met there was a very clear awareness of how littleexperience there is in Bulgaria of NGO development in terms of organisational



administration and management. There is a strong feeling that, unless and until timeand energy are directed at NGO development, NGOs will continue to struggle tosustain existing projects and initiatives. Training and experience are required in areassuch as organisational structure, strategic and action planning, budgeting, staff training, fundraising, and networking. Again there is recognition that such training andexperience could and should be shared and disseminated amongst NGOs if there wassome forum for so doing. A network of NGOs could effectively pool resources and

enable member NGOs to gain experience from each other.

Some NGO members expressed the opinion that the issue of NGO development needsto be addressed first in order that NGO should establish a sound basis from which towork. There was a great deal of interest in the idea of possible assistance with NGOdevelopment training from Penumbra International and a number of specific requestsfor such training.

There is still enormous stigma in Bulgaria regarding mental illness. Most NGOs believeand accept that they have a responsibility to work together to educate both the stateand the public in this area, by raising the profile of mental illness and mental health andby disseminating information about mental health issues. Because their work isessentially community based and carried out largely by volunteers, most NGOs areaware that their workers and services can be more approachable and accessible thanthose funded by the state. Given the existing culture in Bulgaria of trusting to theexperience and knowledge of recognised and familiar state funded professionals andorganisations, a number of NGOs recognise the importance of attracting interest andinvolvement from professionals in the field. The idea is to attract support fromcommitted and well-minded professionals to establish the idea of community care andof service provision by non-governmental organisations as both possible and viable. Asthere is no history or experience in Bulgaria of carer or user groups, many NGOsbelieve that involving such groups will only be achieved via the support of professionals. At present it appears that there are a number of NGOs working on the

same agenda but with no clear process of cooperation. There is a need to establishcommon and shared standards. To this end there was a meeting in January 1998,between some mental health NGOs, to address the need for commonality.To summarise, the NGO sector in Bulgaria is beginning to develop in certain areasthough it is still faced by a number of challenges and difficulties. There is growingrecognition within the sector of the role of NGOs in the Bulgaria of today and of thefuture. There is also acceptance that, in order to fulfil this role, NGOs must develop aseffective organisations, learn to work cooperatively together, gain recognition atgovernment levels, educate the public as well as the state with regard to what the NGOsector is, gain information and experience about external funding and establish regular and clear ways of communicating with service users, carers, professionals and other

agencies. Changes are beginning to take place in terms of government recognition, as Idescribed in pages 11-12. Individual NGOs are beginning to develop links both withother Bulgarian organisations and out with Bulgaria. Moves are being made slowly toeducate the public and to find information about organisational training. There aresome concerns however about the amount of training information with which NGOs arealmost being bombarded. Bulgarian NGOs are aware that they do not have theexperience to make an informed choice and some international organisations, includingPenumbra International, are concerned that the information that is most readilyavailable is not necessarily the best or the most appropriate.



With regard to working cooperatively, this is happening in some areas but it ishampered by an atmosphere of jealousy and at times mistrust. The outline picture,which was described to me by a number of NGO workers, tied in with the impressionthat I myself formed of the dynamics amongst the existing mental health NGOs. Thereare some clear issues, which need to be addressed and clarified, but which are at bestuncomfortable. I was given a great deal of information from a number of sources aboutthe current situation between NGOs. Although it is lengthy to wade through, it does

seem to be important in trying to establish a clear picture and with regard todetermining how and with whom an organisation like Penumbra International mightform a working partnership.

The main issue appears to be around a definite division into two camps. There is agroup of NGOs which, I was told, appears to be “controlled” by the eminent Bulgarianpsychiatrist Toma Tomov and which receives support from the Geneva Initiative onPsychiatry because of the contact with Dr Tomov. I was very aware on arriving inBulgaria that my main contact, Alia Veder from the Neuroscience and Behaviour Foundation, had already been openly critical of Toma Tomov and his” network” as shecalled it. Peter Kampman had identified this during his brief visit to Bulgaria in May1997 and had stated the importance of not allowing this particular view to influence our perceptions. However this view was corroborated by a number of other individuals,both in Sofia and out with the city. Those who spoke out were very clear that they coulddo so without fear because they were not dependent on Dr Tomov for their jobs or for funding for their NGOs. His critics claim that Toma Tomov does not like to be in thelimelight but that he wants to control the situation in Bulgaria and that he uses hisinfluence at the University and with the Geneva Initiative on Psychiatry to do so. Thefeeling is that many of the younger and more recently qualified psychiatrists aredependent on Dr Tomov’s approval and recommendation for employment, so they areunlikely to risk disagreeing with him. It is, for the most part, these young psychiatristswho are taking the initiative in seeing the need for community based projects and whoare therefore instrumental in establishing new mental health NGOs. In terms of

possible funding, there is further criticism that, for example, the Geneva Initiative onPsychiatry only funds or supports funding proposals for projects which Toma Tomovchooses.

The NGOs which are within Toma Tomov’s circle of influence include the Mental HealthSociety of Sofia, the National Association of Mental Health and the proposed but as yetunregistered Balkan Federation. There is criticism regarding money that the MHSS, inpartnership with the Geneva Initiative on Psychiatry, secured from the Ministry of Foreign Affairs of the Netherlands in order to open a day care centre in Sofia. I was toldthat Toma Tomov had supported the application and that the money had apparentlythen gone into an account held by him. I am unsure as to the exact situation in this

instance although I did try, without success, to raise the issue with both Rumen Petrov,the president of MHSS, and with Nicolai Butorin, the project manager for the Van GoghCentre. There does appear to be concern from some corners regarding thetransparency of accounting for funding received for specific projects. This is colouredby the fact that some of the criticism came from NGOs in rural areas and there iscertainly a feeling that Sofia generally attracts more support, both local andinternational, than other areas of Bulgaria.

Another key player within this group of NGOs, and connected in various ways withToma Tomov, is Rumen Ratchev. He was one of the founding members and the past



president of the MHSS and is the initiating force behind the National Association for Mental Health and the Balkan Foundation for Mental Health. I am personally unclear asto exactly what Rumen Ratchev does although he talks a great deal about proposals for action. I heard some mixed reports about the viability of the National Association as atruly national organisation, with doubts being expressed as to how representative it isof NGOs at a national level. The National Association was founded in Plovdiv with,according to Mr Ratchev, four founding members. However the MHSS, one of the

founding members, told me that there were only three member organisations, includingthe MHSS. Boris Boyadjiev, the president of the Bulgarian Psychiatric Association, anda member of the Board of Trustees of the National Association, expressed the opinionthat the National Association is not yet properly established, being only in the initialstages of development as an NGO. He also felt that unless a user representativeorganisation is directly involved in the National Association, it cannot develop as a partof a modern society. There is, as yet, no user organisation involved in the National

Association although I understand that there has been some expression of interest fromsuch a group. According to the president of the MHSS a great deal of work still needsto be done before the National Association can be influential. It has not yet succeededin acting as a coordinating force for mental health NGOs although Rumen Petrov feelsthat Rumen Ratchev is doing some good work in his attempts to network with other NGOs. There is a danger that Sofia is at times isolated other regions. Certainly when Ivisited Targovishte and Shumen there seemed to be little known information about theNational Association and no one had heard of the Balkan Foundation. Even withinSofia there appeared to be a lack of information about the existence of a National

Association; members of the Bulgarian Brief Therapists Society, which coordinates theDay Centre Counselling Service in the premises of Sofia Hospital, had no knowledge of the National Association.

Alia Veder maintains that the Balkan Foundation is just a name and that a number of Balkan countries including Macedonia and Albania have not even been invited to jointhe Foundation. I had occasion to speak briefly with the director of the Mental Health

Association of Dobritch, a Dr Evgheni Georgiev, who stated that he was shocked thatthe president of the Balkan Foundation is a pharmaceutical company representative. Idid in fact meet Julian Zaimov who is the Business Unit Manager of the largepharmaceutical company Janssen Cilag, with particular responsibility for psychiatry. Hewas involved on behalf of Janssen Cilag in hosting a big conference and cocktail partyfor psychiatric staff from the Shumen region. The conference was held in a hotel inShumen that is apparently expensive by Bulgarian standards and certainly chargeswestern prices at the bar. The president of the “Mental Equilibrium” Association inTargovishte, Dr Emilia Dimitrova, who was invited to the conference and whointroduced me to Julian Zaimov, remarked on the lavish expense of such events in theface of the state of the hospitals. Mr Zaimov took some considerable time to tell me

about his reasons for being involved with an NGO, despite his position as a drugcompany representative. He feels that he can use his contacts and his position to thebenefit of the NGO and of mental health in general and that this should over-ride anyprejudice. Nonetheless such prejudice does exist and appears to be a definitestumbling block for some people with regard to the credibility of an organisation suchas the Balkan Foundation.

The second camp of mental health NGOs support and speak favourably of the NationalNetwork of the Bulgarian Mental Health, an organisation which was formed in 1997 bythe Neuroscience and Behaviour Foundation as a club of mental health NGOs



throughout Bulgaria, but which is not yet registered. The coordinator and president of the Network is Alia Veder. At the time of my visit to Bulgaria the Network had fifteenmembers of which at least six are user representative organisations. The existingmembers are fairly well spread geographically, with seven organisations based outsideSofia. Opinions about the work of the Network were all favourable although there wasrecognition that there was a need for more formal organisation. Rumen Ratchev of MHSS remarked that the Network was well based though still informal and in need of

clearer coordination. Representatives from three different NGOs with whom I spoke inShumen and Targovishte all expressed a desire to see the Network develop further.They believe that the Network provides a good forum for the exchange of informationand for learning from the experience of other organisations. There was also verypositive feedback about an initial three-day training session that the Network hadorganised in Varna in May 1997. Users as well as NGO workers attended this session.There is clearly some considerable regret that there has not been sufficient funding tohold another such event.

The impression that I gained regarding the tension between the two camps was that theNetwork was welcomed by NGOs because all member organisations were equal in itand it was seen to be acting on their behalf despite limited resources. On the other hand there were definite concerns amongst those NGOs which had actually heardabout either the National Association or the Balkan Foundation, about their lack of realactivity and that both organisations were, in some respect, linked with Toma Tomov.Given his influence in professional circles the concern appeared to centre on thefeeling that Toma Tomov could exert some control over member organisations. Withinthe Network, all member organisations are clearly independent of the Neuroscienceand Behaviour Foundation with the result that the NBF has no power to influence their decisions.

I am very aware that this section of my report is fairly damning with respect to TomaTomov and some of his contacts and colleagues. I have attempted throughout this

report only to reflect the information and opinions that were shared with me during myvisit and not to express my personal views. My impression of the tensions within theexisting mental health NGOs came from what was said directly to me and also from afeeling that some things were being left deliberately unsaid. There were positivecomments made about the NBF and the Network by people who are closely involvedwith Toma Tomov as well as by completely independent organisations. However when Iattempted to address the concerns that had been expressed to me about Dr Tomovwith some of the people most closely involved with his work in the NGO sector, I had adefinite feeling of avoidance. I do not feel qualified to make a judgement about this but Iam left with a feeling that support from Dr Tomov, as a psychiatrist with very realinfluence and of international renown, is perhaps considered by some to be more

valuable at this stage in the development of mental health services in Bulgaria.



NGO ACTIVITY IN THE FIELD OF MENTAL HEALTH

As I indicated in the Introduction to this report, there are currently a number of non-governmental organisations actively engaged, sometimes against all odds, in providinga variety of community based and free services to people with mental health problems.I was impressed without exception by the creative energy and commitment of thepeople involved in this work. Many of them have stressful and demanding full time jobson which they and their families depend financially; nearly all of them work asvolunteers in their roles as NGO staff; most of them willingly give up their evenings andtheir weekends to be of service to their users. I met with the Executive Director of oneNGO based in Sofia which is embarking on a new project for the prevention of suicidesand which aims to offer, amongst other services, a crisis “hot-line”. This personregularly, and to the obvious detriment of his health and personal relationships, spendsevenings and nights manning the telephone and attending to some of the necessaryadministrative work for the NGO. His commitment, like that of some others whom I met,

is such that he cannot readily turn his back on the very clear and desperate needs of the people around him, despite the cost to himself as a person. However without thefunding to provide salaries in addition to covering the costs of running projects, NGOstaff continue to struggle with this dilemma.In terms of real action and projects which are already being implemented, I was againimpressed by the how much was being achieved in some areas with next to noresources. The following section of this report gives specific details of the areas of activity and interest of the NGOs with which I made contact while in Bulgaria. Some of the projects were already in action when I visited in March 1998, while others were stillproposals. I include any recent and up-to-date information that I have received sincemy visit.

The organisations mentioned below are not in any order of merit but follow thechronology of my visit (see Appendix III). Contact details and an outline of the areas of activity of some of their organisations can be found in the 1998 NGO Directory for Organisations working in mental health in Central and Eastern Europe, as compiledand published by Penumbra International and the Romanian League for Mental Health.

Neuroscience and Behaviour Foundation (NBF)

This organisation was established as an NGO in Sofia in 1991. Its aims are “Toempower the work in the field of neuroscience and behavioural sciences through

citizens’ support and to contribute to the psychosocial culture of the society.” NBF hasa wide programme of activities focusing on research, education and training. Itsactivities and areas of interest include the following: gypsies - life style and health;psycho-educational programme for children with autism, their parents and carers;training for volunteers for mental health projects; training of students as mental healthproject volunteers; training in fundraising in the field of mental health; a national grantprogramme for research projects in behavioural science; the contribution of NGOs inBulgaria to the issue of Human Rights and Mental Health; the production of a mentalhealth bulletin in both English and Bulgarian. NBF has also been closely involved withand supportive of a number of translation and publication programmes of mental health



related documentation and literature. This work has been carried out in partnership withthe Bulgarian Psychiatric Association (NGO) and the National Centre for Interdisciplinary Human Studies.

NBF is actively and continuously involved in fundraising both for its own projects and inorder to secure funds to support other NGOs with similar areas of interest. It stronglysupports the idea of cooperation and networking between NGOs and to this end hasbeen the creating force behind the establishment of the National Network of BulgarianMental Health NGOs. The organisation is eager to make contact with internationalagencies and is clearly successful in so doing. Having heard of PenumbraInternational’s work in Romania, the Director of NBF invited Peter Kampman to visitBulgaria with a view to possibly forming a partnership to undertake a programme of NGO development. As mentioned in the Introduction, this was our first contact withBulgaria.

A General Council manages this Foundation with responsibility to define and oversee

NBF policy and to approve the annual budget and the Executive Board. The Board iselected by the Council and consists of the Chairman of the Board of Experts, theDirector and 4 other members. There is also a Control Board that, while elected by theCouncil, has control over the Council’s decisions.

The National Association for Mental Health

This organisation was founded in Plovdiv with originally two members and anexpression of interest from a third organisation. The National Association has anExecutive Board compiled of a president, a vice-president, a secretary and a

treasurer/financial officer who is apparently the representative of one of the main tradeunions in Bulgaria and has personal contacts within government circles. There is also aBoard of nine Trustees. According to Rumen Ratchev who I understand is now thevice-president (although when I met him in March 1998 he was the president), therewere approximately ten NGOs actively involved in the aims of the National Associationalthough they were not all members. All member NGOs must be registered, working inthe field of mental health, complying with the policies of the World Federation for Mental Health and supportive of the aims and ideology of the Association. The

Association is aimed mainly at NGOs working in psychiatry rather than learningdisabilities, although both are possible. As a child psychologist, Rumen Ratchev iskeen to involve organisations working with children.

The Association aims to assist and support its member organisations, especially newlyestablished organisations both within Sofia and in other regions. Mr Ratchev is also theinitiator of the idea for a National Forum of NGOs. He hopes to be able to establish anational forum for NGOs throughout Bulgaria to meet together in order to address theneed for cooperation between NGOs. His aim is that the National Association for Mental Health will be one branch of this coalition of NGOs with a particular focus onmental health. The intention is that a Consultative Council will be formed from theNational Forum of NGOs that will provide a line of communication between NGOs andthe government.



Currently the National Association needs funding for office space and at least onesalaried worker. It relies on the possibility of using the offices of other NGOs thatmakes it difficult to develop as an organisation or to progress with some of theinitiatives that it has started. The lack of funding also prevents the Association fromimplementing any specific projects. I was told that applications for funding have beenmade to the Civil Society Development Association in Bulgaria and to the DemocracyNetwork Programme in the USA, although without success as yet. Mr Ratchev feelsthat the most important first step is to buy a small flat in which to establish an office andto begin working initially with volunteers. He would be interested in assistance fromPenumbra International to achieve this and also expressed a need for some methodicalassistance to develop both the National Association and the various projects. Heparticularly specified training for NGOs that focused on developing human resources.

As yet there is no training available for leaders of NGOs although Mr Ratchev spoke of an initiative with the New Bulgarian University that would focus on compiling aprogramme for NGO leaders, based on western methods. Once trained, the studentscould then become NGO leaders and train others, thus hopefully achieving fairly fast

results. Rumen Ratchev feels that an accredited training programme is necessary.

It would appear that all these initiatives are still at the proposal stage, due mainly tolack of money to implement any of them. There was some mention made of the FamilyRelation College in Sofia for which initial funding came from the Democracy NetworkProgramme in America. I am unclear as to exact relationship between the National

Association and the Family Relation College but the Association appears to beinvolved in some way in securing funding for the College. I was invited to attend theFamily Relation College Conference on 3 March 1998 followed by a meeting of the“ruling bodies” of the National Association in the evening. Unfortunately I was due toleave Bulgaria on that day and could not therefore be present.

I have recently learned that Mr Ratchev appears to be somewhat disillusioned with theidea of a National Association and seems to be dissociating himself from it. Members of the executive committee are expressing concerns and there is evidence of a seeminglack of communication about administrative matters. It is difficult to determine howmuch of this is true.

Bulgarian Psychiatric Association

The BPA was founded in 1992 and has both individual and group members, mainlycomprising psychiatrists and clinical psychologists. The organisation describes itself as

being “an observer, critic and advocate in the field of mental health in the country(Bulgaria)” and its aims include attempting to carry out legislative reform, the activepromotion of mental health and the improvement of mental health care. The position of the BPA on reform can be summarised in a vow for development as opposed tosurvival. The BPA believes that psychiatry needs to move away from its traditionallyheld image of control over the mental life of individuals and to become more responsiveand accessible and therefore better able to address the changes taking place in thelives of the Bulgarian people, especially during the current period of transition.

Structurally a Board of Trustees, an Executive Board of which the current president is





persistent psychiatric problems”. The programme has been adapted from a programmerun by the University of California, involving structured modules that focus on training insocial and community living skills such as basic conversation skills. The projectManager, Nikolai Butorin, has personal experience of working with these modules thathe believes stimulate people to be more interactive in society and the community. Thisproject is also intended to act as a pilot for other such centres. MHSS has a long-termvision to create good examples of well functioning community based projects in Sofia,which can then be used elsewhere. The intention is that the Van Gogh Centre willprovide a model of a day care centre that can be developed to be used throughoutBulgaria. MHSS hopes that, as such centres are established and develop in other areas, students and mental health professionals who are interested in this type of community-based work will come to look around and to receive training. MHSS hasapparently met with the Ministry of Health in order to promote this model of service as aviable way forward.

I understand that there continue to be some difficulties around the actual

implementation of the project. Concern was expressed to me in March 1998 that thefunding secured from the Netherlands would not be enough to cover the rent for premises for the project. The municipality of Sofia was not forthcoming about assistingwith accommodation though MHSS believe firmly that the state should support suchinitiatives and even request them as possible teaching instruments. Currently thegovernment is approachable but support from both central and local authoritiescontinues to be verbal rather than practical. In addition there appears to be concernamongst local people as a result of continuing stigma around mental illness. Inevitablythese difficulties cause delays which potential users find frustrating. While I was inSofia, a number of members of the Social Club complained about these delays, as theywere aware that the funding had been available since December 1997.

In addition to the activities detailed above, MHSS is also involved in working with thegypsy community in Plovdiv. Plovdiv is situated about 100 kilometres from Sofia and isa town with a large Roma population where, in some areas, there is clear evidence of extreme poverty, with little or no running water and no sanitation. Within the Romacommunity in Plovdiv there is a group of individuals interested and keen to work withMHSS and to use their experience of project implementation. Together they hope toestablish a social centre for users and families of users of mental health services. Goodlinks have also been established between MHSS and the University in Burgas, on theBlack Sea. A group from the University has started to set up various projects workingwith gypsies, women and children. Depending on funding for travel expenses, it issometimes possible for project workers from Sofia to visit outlying areas in order to

share their experience.

Over the past couple of years, MHSS feels that it has been finding its identity and that itis gravitating towards community care. The main concerns which members of theorganisation expressed during my visit were 1) how to attract people who are eager enough, brave enough and trained enough to be a part of the community based workwith which MHSS is involved, especially in the face of existing stigma, 2) how to securesufficient funding to develop the work of the organisation when the government givesno such support. The programme which MHSS has drafted for the future includes



providing education and information about mental health issues, providing support for young professionals who are caught between the expectations and demands of traditional psychiatry and the growing voice of users, sharing its experience of projectimplementation and disseminating examples of good practice.

Trust Line

Trust Line is an initiative that is run by volunteer psychiatrists with some assistancefrom a group of psychology students. It is supported by the Bulgarian Red Cross andprovides a phone-in help line for anyone in need of help. The examples that I wasgiven included children, vulnerable people, the elderly, and people with mental healthproblems. The service is manned 24 hours a day and receives on average 69 calls per week, approximately 3000 per annum. From what I was told and from the examplesgiven, it appears that the counselling help that is given is quite traditional. Certainly thepsychiatrists whom I met and who are involved with Trust Line were very fixed in their

ideas.

Miloserdie Foundation

This NGO is a small organisation that runs a hospice and provides support servicessuch as meals-on-wheels for the terminally ill and for other groups of vulnerable peopleincluding the elderly and those with mental health difficulties. Miloserdie Foundation islinked with the Central and Eastern European Network and has received some EUfunding. The Foundation has some contact with Help Age International.



Bulgarian Brief Therapists’ Society

This NGO was established and registered in 1994. I am unclear as to the specific aimsof this organisation as I am still waiting for more information. According to BoyanStrahilov, brief therapy is an approach that is very appropriate to Bulgaria as Bulgariansociety and culture is generally permissive with very few taboos. The therapy focuseson decision making and coping strategies, using the power of language. It is based on

system thinking and problem solving and developed in Europe and the States in the1970s.

Training in psychotherapy is limited and incomplete in Bulgaria with very fewapproaches being developed. Brief Therapy focuses on the family as a resource andthis Society uses the family therapy approach in the work that it does through a DayCentre Service that is held in the grounds of Sofia Hospital. The Day Centre offers itsusers alternatives to psychiatry, including family therapy. However, as I mentioned inthe section on Care and Service Provision, there is ongoing conflict between the DayCentre and the Hospital over the issue of drug treatment in addition to the fact thatusers are reluctant to use the Centre because of its proximity to the Hospital. There isconcern that this project cannot survive for much longer however due to lack of funding.Sofia Hospital has refused to help with funding for the service. The Brief Therapists’Society has applied to both the Phare programme and to the Soros Foundation for assistance but without success. Members of the Society told me that they need tospend much of their time finding out information about possible funding sources assuch information is not readily available or accessible. An application was submitted toCranfield University in England for assistance with training in NGO management, butwas refused. As with other organisations, this Society has no real experience of NGOdevelopment in terms of administration and management. Most projects take at least ayear before they are established and active, by which time the funding often runs out,resulting in the collapse of the project.

Members of the Society also identified difficulties of which they are aware in their attempts to form a network of psychotherapists and counsellors, difficulties that theyfeel arise from their lack of experience of how to network successfully. Since therapy asan alternative to psychiatry is still a new idea in Bulgaria, organisations like the Brief Therapists’ Society find it difficult to advertise and to promote their service. Ideally theDay Centre aims to provide a direct and free service, supported by external funding.The Society hopes that eventually a network of such centres will be created across thecountry.Club of the Ex-Patients (Shumen)

This NGO has been active in the Shumen region since 1996. Its members include ex-

patients and users of mental health services, families of users, specialists, psychiatristsand volunteers. The Club provides a meeting place for its members and acts as anetwork for support. The NGO aims to contribute to the re-socialisation of ex-patientsand users of mental health services and to promote mental health as a basic need.

Along with disseminating information about mental health issues, the Club wishes towork towards ensuring that appropriate medication and treatment are regularly andreadily available for patients and users and that there is some financial support for their daily needs.

The Ex-Patients’ Club has no real funding other than a government grant of £10 per



year, which is the equivalent of the registration fee. The Club has no resources other than the use of a house which is provided free of charge by the municipality. Equallythere is no technical equipment available. All the workers with the NGO are volunteers.Employment opportunities for users are not normal practice in Bulgaria, exceptoccasionally within hospitals. Thus there are no income possibilities in this area for NGOs. There is clear recognition amongst the members of this Club of the need todevelop as an established NGO. To this end members have already participated in an

initial training programme run by the National Network of Bulgarian Mental HealthNGOs and they spoke very positively about the programme and its benefits. Thetraining needs which Drs Penkova and Nikolova expressed during our meeting focuson the following areas:

• Basic administrative and management training. The NGO has no clear administrative structure as yet and recognises the importance and need of acquiring such know how as soon as possible. Without this there is littleopportunity of developing as an effective NGO. Once established in this area,the Club would like to contact the local media in order to advertise its services.Skills in project development and compiling appropriate programmes are alsorequired along with training in how to make most effective use of existing andnew communication networks.

• Fundraising and, in particular, how to create clear project proposals. The Clubhas little access to information about possible funding and no experience of applying for funding should the information be available.

The Ex-Patients’ Club is interested in exploring the possibilities of tool kits andinformation packs as a means of developing as an organisation. There is a strongbelief within this group that NGOs need to develop as effective organisations in the firstinstance and then work together to educate people about the work of the NGO sector as a whole and to address the issue of stigma by raising the profile of mental health

through information and education. There is also an active desire to include users intraining initiatives. Apparently 7 users from Shumen attended the training session inVarna (see page 20) and returned feeling empowered and informed about thepossibilities of NGO activity. Unfortunately there are usually insufficient resources for more than 2 or 3 representatives to attend training sessions.

Balkan Federation for Mental Health

Despite meeting with Julian Zaimov who is on the Executive Committee of theFederation, I could not find out any information about this organisation. It appears to be

just a name at this stage.



Mental Health Society of Targovishte

This organisation has developed out of a club called Club “Health” which has beenactive since 1991 with a membership of ex-patients, service users and supporters of mental health issues. The Mental Health Society was officially registered in 1996 with26 members at that time. The Society aims to improve the quality of life of people withmental health difficulties; to be active in the field of legislation; to provide realistic andaccurate information about mental health issues; to help individuals to gain a better understanding of their own mental health problems; to actively pursue and developcontacts with other similar organisations with a view to sharing experience and workingcooperatively together to promote mental health; to work from a trans-culturalperspective in order to support different ethnic groups. The Society has some Turkishand Roma members.

I met with some members of this Society and was impressed by their clarity of directionand by the interest that they expressed in their rights as service users to influence

legislation and policy. Advocacy and accurate representation are high on their list of priorities. Once again funding is an important issue and many views were sharedregarding the lack of employment opportunities for service users in the Bulgaria of today. Members expressed ideas for possible income generating projects but withoutthe necessary start-up funding the projects cannot be realised. I received requests for assistance from Penumbra International in securing funding for such projects. Alsothere were requests for assistance with training in organisational development and inhow to market products, in the event of the income generating projects being realised.

Other proposed projects and areas of activity include the development of social policyrelating to Advocacy and Human Rights issues for people with mental health problems;

work with women and children who are the victims of violence; research into mentalillness in a trans-cultural context; work with AIDS sufferers and drug addiction includinga programme for installing blood-testing equipment in local areas; working inpartnership with the “Mental Equilibrium” Association to address the issue of mentalhealth and human rights in the Targovishte area.

“Mental Equilibrium” Association (Targovishte)

This organisation consists mainly of professionals (psychiatrist, social workerspsychologists and others) from the town of Targovishte and its surrounding area whoare involved in, or have an interest in, the field of mental health. The Association has

close links with the Mental Health Society of Targovishte and shares some of its aims.Its main objectives are to contribute to the improvement of mental health services in theregion; to assist its members in gaining better medical qualifications, experience andtraining; to research and provide medical evidence of the need for specific projects.The organisation’s programme of activities includes a project to initiate change in thestructure of psychiatric services in the region; the promotion of mental health throughcooperation with the media; research into the area of genetics and mental illness; workwith children and adolescents at risk particularly from drug addiction; the creation of adata-base for information on mental health issues; the development of partnershipswith other organisations, local, national and international. The Association already has



active links with the Neuroscience and Behaviour Foundation and the Mental healthSociety of Targovishte. Members of this organisation also work together in smallgroups of 3 or 4 to visit outlying areas in order to provide a community based follow-upcare service. They focus on assessing difficulties, checking medication, providinginformation etc.

Members of “Mental Equilibrium” Association acquired funding from the Bulgariangovernment to establish a Drug Abuse Centre that provides, amongst other services,an outreach programme which moves round the region. Courses are available on drugprevention, targeted particularly at children and adolescents. The Clinic is working inpartnership with the National Drug Centre in an attempt to manage the drug problem inschools. A training course is being run this year to enable teachers to learn how tospeak with pupils about drug related issues. The Clinic is run from premises that areseparate from the hospital. There is a 24-hour help line with an answer machine that ischecked every 4 hours. Four volunteer workers man the help line. In addition theproject is involved in compiling and distributing leaflets.

Initially the government provided 100% of the funding necessary to establish thisproject. However the Clinic now has to fund itself without any assistance from thegovernment. An application has been submitted to the EC for support. Life Foundationhas helped the project with this application. Training in fundraising is once again apriority with this organisation.

LIFE Foundation (Targovishte)

LIFE Foundation was established in 1996 working in the areas of health services,

education and social welfare. It is dedicated to the improvement of the state of healthcare and disease prevention in the Targovishte region by developing educational andmedicinal programmes and by assisting the regional hospitals through donations of medical equipment and medicines. It also organizes conferences and seminars aimedat furthering the learning and experience of local professionals and at improving thehealth culture of young people in the area. LIFE Foundation has for example publishedsome educational leaflets on the issues of safe sex and AIDS prevention aimedprimarily at young people.The foundation is staffed by 7 volunteers and greatly values the possibility of closecooperation with similar organisations both in Bulgaria and elsewhere.



National Network of Bulgarian Mental Health NGOs

Although still in the process of being registered, the National Network of BulgarianMental Health NGOs has already succeeded in attracting some 14 or 15 members andhas successfully run a training initiative for both NGO workers and service users andcarers. This organisation was initially formed as a club of mental health NGOs in 1997.Its aims are to co-ordinate, on a national basis, the activities of Bulgarian mental healthNGOs interested in contributing to the development and empowerment of its membersand to mental health promotion throughout the country. These activities will focus onthe sharing of information, cooperative working and training initiatives. The Networkalso aims to support the establishment of user organisations and to provide appropriatetraining in the areas of self-help and mutual support.

Many of the existing member organisations come from the country regions of Bulgariaand often lack access to basic information about training programmes or other NGOevents and projects that is more readily available to NGOs working in and around

Sofia.

The Network has already evoked praise and positive feedback for its initial work increating a forum for NGOs to come together for support and to share information andskills. A number of the NGOs with which I met expressed enthusiasm for thecontinuation of the Network as an invaluable resource for developing mental healthorganisations. Lack of funding has meant that it has not yet been possible to run further training programmes.

“Budnina” Foundation

The “Budnina” Foundation has been active as an NGO since 1994 with its main aimsfocusing on providing support and assistance for marginalised groups and individualswho are experiencing serious difficulties whether of a social, financial, health (bothphysical and mental) or legal nature. The organisation aims to “overcome thealienation, desperation and suffering which these problems cause by creatingacceptable conditions for existence”. The “Budnina” Foundation is involved in a number of activities such as providing a social network for its target groups; interacting andcooperating with the mass media and with various legal, social, educational and healthservices; creating and running training programmes for healthy living; engaging andenlisting public opinion and support with regard to the issues outlined above.

One of the projects that the “Budnina” Foundation undertook recently, together with theNew Bulgarian University, involved the production of a documentary film entitled“Suicide”. The organisation is currently trying to secure funding for a project that willprovide a “Protected Social Network for People with Suicidal Behaviour”. Although theproject will initially be based in Sofia, the aim is to ensure that appropriate support andcrisis intervention are accessible across the country by the creation of an efficientnetwork. In addition to providing support and information to people in crisis situationsand their families, the project aims to inform and educate society with regard to thetragedy of suicide and to form active and productive relations with other agencies thathave contact with people at risk.



The Foundation has a Management Board with a Chair and 3 Board Members, 1 of whom is the Executive Director. A team of 10 volunteers carries out the activities of theFoundation. As with many other Bulgarian NGOs, the “Budnina” Foundation recognisesthat it needs training in a number of areas in order to develop as an effectiveorganisation. The areas which the Foundation have specified include: management,budgeting and accountancy, fundraising, networking and forming partnerships, IT andcommunication skills.



OTHER AGENCIES

While in Bulgaria I had the opportunity to spend some considerable time hearing aboutthe work and activities of the National Centre for Interdisciplinary Human Studiesthat is financed by the government and answers to the Ministry of Health. The NationalCentre is a non-traditional research establishment with no laboratories or clinicalfacilities and no research personnel. Its work is organised and coordinated by aminimal administrative staff. All research and training activities are carried out asprojects undertaken on a contract basis by teams that are specially formed for thatreason.

The National Centre focuses its activities around areas such as patients’ human rights,mental health legislation, assessment of care needs, development of community mentalhealth services, users’ involvement in the planning and monitoring of mental healthpolicy and service, the integration of mental health and primary health care etc. Its

main functions are to initiate, organise and coordinate the following activities:

• The research of human behaviour in the field of neuroscience, social anddevelopmental sciences, mental health and health behaviour

• The collection and dissemination of information and transfer of know-how intomental health practice

• The training of professionals in the field of public health, psychiatry, educationand other related professions

• Surveys, analyses, expertise and programmes for the formulation and realisationof national mental health policies

The Centre is very keen to develop partnerships with foreign groups and many areas of the Centre’s work are achieved in collaboration with organisations and agencies fromabroad. The publishing programme is carried out with the support of the Neuroscienceand Behaviour Foundation and the Geneva Initiative on Psychiatry, in addition to someassistance from the British Embassy in Bulgaria. The National Centre is also thedesignated WHO Collaborating Centre in Research and Training in Mental Health inBulgaria.

Recently the National Centre has begun to establish contact and form partnerships witha number of Bulgarian NGOs of both users and professionals. These partnerships haveresulted in some joint projects such as conferences and training initiatives. The Centrehas close links with the Bulgarian Psychiatric Association and the neuroscience and

Behaviour Foundation in particular.

I also learnt about the work of the Department of Medical Ecology and Nutrition atthe Centre of Hygiene in Sofia. Some of the Heads of the Department, whose workfocuses mainly on the areas of child hygiene and nutrition, expressed a wish to meetwith me in order to discuss work which they are currently doing in the area of exploringthe links between the physical and the psychosocial needs of children at risk. Staff working in the areas of child hygiene and nutrition have joined forces in an attempt tobest address the needs of children at risk. Over the past 4 years, research has takenplace on a national basis into the physical and psychosocial needs of children in social



homes. There are apparently over 20,000 children living in social homes in Bulgaria, afigure which staff at the Centre of Hygiene find very high compared with the totalpopulation. Any nation wide investigation is difficult to undertake as the children are of varying ages, ranging from 0 to 18 years, and live in different administrative regions;there are regional differences that must also be taken into account.

Children who live in care from the age of 0 to 3 years should be placed in homes for mothers and children but are, in reality, usually put into orphanages under themanagement of the Ministry of Health. From the age of 3 to 18 the children are movedto other homes that are the responsibility of the Ministry of Science and Education. Agroup of children with perceived learning difficulties (although no proper needsassessment is carried out) are however sent to homes managed by the Ministry of Social Welfare. A further group, often with chronic or permanent physical difficultiessuch as asthma, blindness or deafness, live in recreational schools under the

jurisdiction of the Ministries of Health and of Education. Also there are residentialschools that come under the name “Education by work”, for children who have

committed crimes. The Ministries of Internal Affairs (police) and of Education have jointresponsibility for these establishments. Understandably there are difficulties in tryingto ensure some level of cooperation and collaboration between the various Ministries,and in trying to form a coherent policy for the appropriate care of children at risk.

There are serious problems for children after they leave the comparative shelter of thevarious institutions mentioned above, as many of them have no homes or families to goto and few skills to assist them in adapting to adult life on their own. Given theeconomic situation in Bulgaria, there is no real financial aid for these youngsters andthere is stiff competition for jobs. In an attempt to address this problem, severalpsychosocial programmes have recently been started for children in various

institutions, focusing on areas such as basic academic achievement, social skills andregular nutrition. The staffs with whom I met at the Centre of Hygiene, who are involvedin these programmes, provided me with a list of their specific areas of concern andmade various requests for information and expertise to assist them in improving their current service. They wish to find more effective ways of working by learning from theexperience of others working in the same field. Good practice documents have beenrequested on working with children at risk.



IN CONCLUSION

What struck me most out of the many experiences of my first visit to Bulgaria, and thememory which remains strongest nine months on, is to do with the remarkable andinspiring sense of there being a job to do and that now is the time to do it. Of coursethere is despondency and frustration and at times a feeling of wanting to roll over andaccept whatever happens, in the hope that it might just be an improvement on the

reality of the present situation. Given the recent years of turmoil and change, this stateof exhaustion is easily understood. How do people, after years of being told how andalmost when to live, suddenly find or create the resources to start living on their ownstrength? And yet, certainly amongst the people with whom I met, there is an invasivefeeling that the past is past and there are lessons to be learned and experiences to beused which can help in building a future which is worth living. As I said earlier in thereport, with specific reference to the state of mental health services, I was impressed bythe growing awareness amongst both service users and some professionals of issuessuch as the need for advocacy and the importance of the individual to be involved indetermining his\her own future. I was also struck by the fact that, when asked how anorganisation like InterMinds might be of use or of help to existing and emergent NGOs,nearly all the replies focused on requests for information, assistance with training andNGO development, followed by requests for funding. Certainly most of theorganisations that I visited have few resources if any. Most of the people involved in theNGO sector work as volunteers and rely on the goodwill of their employers or the localmunicipal authorities for basics like meeting premises or office equipment. However despite this, there is a realistic recognition of the importance of establishing NGOs aseffective organisations that have the inbuilt skills and resources to support, sustain andcarry out their aims.

There is clearly an enormous amount of work to be done in Bulgaria in order toestablish a system of care and service provision which adequately and appropriatelyanswers the needs of people with mental health problems. In the first instance mental

health must appear on the health agenda with the forming of specific mental healthlegislation and policies which clearly reflect today’s world. This is beginning to happenunder the existing government and will be further supported by the appointment of Dr Toma Tomov as President of the Association of Mental Health Reformers in EasternEurope, to be based in Sofia. The voices of the voluntary sector are beginning to beheard through the creation of posts such as that of the Chief Advisor to the Minister of Social Affairs (see page 11) and the recognition that groups such as a ConsultativeCouncil of NGOs have a valid and important part to play in accurately reflecting theneeds of service users. There is still considerable reluctance on the part of psychiatrists from the more traditional schools; to support the concept of communitybased care. This, along with continuing stigma around the whole issue of mental illness

and lack of information about what NGOs are, makes the task even more difficult for local NGOs eager to establish projects in the community. Concerned parties haveidentified the urgent need for efforts to be directed towards raising the profile of mentalillness and towards mental health promotion. The culture of compliance andacceptance that is prevalent throughout Bulgarian society needs to be broken in order that mental health legislation and practice might change. Also people need to beeducated about the potential of non-governmental organisations.

With regard to the development of community based projects and services specificallytargeted towards people with mental health difficulties, there are a number of initiatives



already in place, some of which are described in the section entitled “NGO Activity inthe Field of Mental Health”. However, for the most part, they lack the backing of a well-established organisation with the resources and know how to adequately support anddevelop such projects. There is a clear role here for an organisation like PenumbraInternational, which has the experience and expertise to assist local groups to developas effective NGOs. Penumbra International can provide specialised staff andorganisational training to support such development. Also, in partnership with local

mental health organisations, Penumbra International has the skills and experience toassist such organisations to establish, develop and sustain community based projectswhich will provide appropriate and accessible services in answer to previouslyassessed and identified needs.

Furthermore, and in response to a specific request for assistance in this area,Penumbra International is keen to play a part in developing a strong and effectivenational network of mental health NGOs. Such a group has already been formed andhas been enthusiastically received by its members. There is clear recognition of thevalue and importance of a unified and cooperative network, which can provide anappropriate forum for discussion, support and skills exchanges between NGOs workingin the same field. There is also considerable interest in the possibilities of such anetwork gaining recognition and acceptance as a truly national organisation with animportant and valid role to play in coordinating and representing the voice of itsmembers and most especially of its user members.

To summarise, a start has been made. In certain areas of the population there is agrowing awareness, both that the existing situation with regard to mental health can nolonger be tolerated and that the task ahead is enormous, involving cultural as well aslegislative, economic and professional issues; there is a thirst for information and adefinite and determined feeling amongst informed groups that the time is right for action. The message that I received throughout my visit was a clear request for assistance from international organisations, experienced in mental health issues and

willing to work in partnership with local organisations. There is acknowledgment nowthat the state has not, in the past, and cannot, in the future, provide all the answers.One psychiatrist whom I met in Shumen, told me that she believed that she had a clear position, both in her professional capacity and as a social being, to provide (“patients”)people with mental health difficulties with the care and support which they need. Sheunderlined her belief that society, as a whole must share this responsibility with thestate. I found this statement particularly encouraging, considering both Bulgaria’scultural and historical response to mental illness and its recent experience of communist rule.



APPENDIX IPublic Health Act (1973)

Article 2

1. Every Bulgarian citizen has the right to free of charge medical care in publichealth services on the conditions of this Act.

2. The government takes comprehensive measures for preserving and restoringthe health of citizens and provides free, accessible and qualified medical care,setting up the necessary network of public health establishments.

4. Besides of public health institutions, medical care can be given in healthinstitutions of physical and legal persons, as well as in clinics of medicalspecialists on private practice.

Article 25a

1. Only certified medical specialists have the right to pursue private medicalpractice.

Article 36

3. Liable to compulsory treatment in public health establishments are patients withmental disorders, specified in the Application Rules of this Act, after their beingexamined by a commission of specialists.

4. All admissions of patients under the above paragraph are carried out only upona Local Court’s decision, following the procedure specified in Articles 59 (page

2), 61 (pages 1,3,4) and 61 (page 1) of this Act. When the patient’s conditionmakes impossible his appearance in court, he is visited and heard out in thehospital.

5. When the patient’s condition requires immediate treatment the Head of thehealth establishment may order an admission for temporary treatment informingimmediately the local attorney who summons the court for taking a decision,mentioned in the above paragraph.

6. The compulsory treatment in a hospital is discontinued when it is deemed nomore necessary. In any case if the treatment is continued the court shouldreconsider the case every year with regard its continuation or discontinuation.



Article 59(?)

1. (Patients).... who refuse to take treatment or dissuade from a voluntary one andwho, due to the alcohol or drug abuse, seriously damage their own health or withtheir conduct create danger for their families or offend the public order and thesocialist morals are liable to compulsory treatment.

2. The admission is carried out upon a decision of the Local Court, summonedupon the Local Attorney’s proposal.

Article 60

Signals to the local Attorney may be issued by the social organisations, theSobriety committees, the people’s Voluntary Groups of Order, therepresentatives of the Ministry of Home Affairs, the health establishments andother state institutions, as well as by citizens.

Article 61

1. The Local Attorney makes a proposal based on a check-up and a medicalexpert’s conclusion.

2. The Court sends a copy of the proposal to the person whose compulsorytreatment is being demanded. The latter may reply within seven days andindicate proofs for his thesis.

Article 62

1. Within a couple of weeks after the proposal has been deposited the case isconsidered by the Court in an open session in the presence of the Attorney and

the person whose compulsory treatment has been demanded.

2. If the person does not come voluntarily for an examination or does not attend thesession having no valid reasons for that, he is brought up compulsorily.

Article 63

1. The Court answers the Attorney’s proposal, after the person has been heard out,with a decision, based on the evidence gathered.

2. When the Attorney’s proposal is deemed valid, the Court specifies the

specialised health establishment and the period of the compulsory treatment.The period may not exceed one year.

3. The Court’s decision can be appealed against at the District Court within sevendays after being announced. The procedure before the Local and the Districtcourt is ruled by the norms of the Penal Procedure Code so far as no specialrules are contained in this chapter.

4. The effected decision is executed by the health institution to whom the policemay give assistance, if needed.



Article 64

1. Summoned by an Attorney’s proposal based on a medical expert’s conclusion,the Court may discontinue the compulsory treatment in an open session.

2. When the person is not cured in the decided period of time the Court,

summoned by an Attorney’s proposal and on the basis of a medical expert’sconclusion may enact a new decision for compulsory treatment, following theprocedure mentioned.

Article 65

1. The compulsory treatment is carried out in specialised health establishments,organised by the Ministry of public Health in co-operation with the People’sCouncils.

2. The compulsory treatment is combined with work therapy in workshops andfarms, founded at the specialised health establishments for that purpose. Thepatients’ labour is paid accordingly.

Article 66

Stoppages are made of the pay, mentioned above to meet partially theexpenditures for the patients’ living at the establishment and the rest of the sumtotal is sent to those owed alimony by the patient. The rate of the stoppages isspecified by the Minister of Public Health in cooperation with the Minister of Finance.

Article 67

The compulsory treatment having been finished, the People’s Councils at theresidence and at the workplace of the patient, at a request made by the healthestablishment take steps to arrange his work and living conditions and to protecthim from repeating the alcohol or drug abuse.



APPENDIX IIRules for Application of the public Health Act (1977)

Article 67

Liable to admission for obligatory treatment under the terms or article 36 (p 3) of the PHA are individuals suffering from schizophrenia, cyclophrenia, epilepsy,senile, presenile, traumatic, vascular and organic mental disorders; infectious,somatogenic, psychogenic and toxic psychoses, oligophrenia and severepersonality disorders, who, due to their illness, may commit a serious legaloffense or are dangerous for their relatives or for the community or seriouslyendanger their own health.

Article 68

1. The Attorney may be notified by state or social organisations, healthestablishments, relatives and other citizens of the need to proceed for anobligatory treatment of mentally ill individuals.

2. Signals and proposals from the health establishments should be accompaniedby medical documentation, motivating the need for treatment.

Article 69

The Head of psychiatric health establishment may summon the Attorney with aproposal for obligatory detention of a mentally ill, who was voluntarily admitted,but during the treatment course insists on being released, if the requirements of article 67 of RAPHA are present.

Article 70

1. In cases when the condition of the mentally ill makes immediate measuresnecessary and he has been temporarily admitted following the procedure of article 36 (p 5) of PHA the Head of the establishment should inform the Local

Attorney within 24 hours, following admission.

2. If the Attorney refuses to make a proposal in the cases, specified by article 69and by the above paragraph, the health establishment should release the patientimmediately.

Article 71

The Court’s decision for obligatory admission is executed by the appropriatepsycho-neurologic dispensary at the patient’s residence and in cases of disobedience - with the cooperation of the Ministry of Home Affairs’representatives.

Article 72

The psychiatric establishment informs the patient’s relatives immediately after



his being admitted for obligatory treatment.

Article 73

1. When the obligatory treatment is deemed no more necessary the Head of psychiatric establishment sends a proposal for its discontinuation to the Local

Attorney, accompanied by the appropriate medical expert’s report.

2. In any case, by the end of the first and every next year of the obligatoryadmission, the Head of the establishment sends a motivated opinion for either continuation or discontinuation of obligatory treatment to the Local Attorney,accompanied by an appropriate medical expert’s report. The opinion should besent in due time, so that the Court would be able to take a decision aboutcontinuation or discontinuation of the treatment before the year has passed.

3. If the Court decides to discontinue the compulsory treatment, the healthestablishment should release the admitted immediately.

Part 5: Work Therapy

Article 98

Work therapy farms and workshops may be organised at the healthestablishments for Work therapy of both in-patients and out-patients to becarried out.

Article 99

1. The Work therapy farms and workshops are either financed by the state or

financially autonomous, but not incorporated.

2. The Work therapy farms and workshops at the health establishments under thePeople’s Councils are given financial autonomy by a decision of the DistrictPeople’s Council Executive Committee, while those at the establishmentssubordinated directly to the Ministry of Public Health - by an order of the Minister of Public Health

Article 101

All good produced and services performed by the Work therapy farms and

workshops are tax-free.

Article 102

The Work therapy farms’ and workshops’ industrial production is sold under theterms and at prices after the Rules of Prices. The agricultural production is soldpreferentially to health establishments and state and cooperative organisationsat market prices.

Article 103



For work and treatment at the Work therapy farms and workshops at the psycho-neurological establishments, disabled patients of 2nd and 3rd groups may beaccepted. Mentally disabled patients of 3rd group may be employed there asregular workers too.

Article 104

1. The types of work that may be performed by the patients are specified by thephysician in charge of the Work therapy at the health establishment.

2. The patient’s work time should not exceed 6 hours under conditions specified bythe physician who has indicated Work therapy.

Article 105

1. The labour of patients in Work therapy is paid in accordance with the fixedproduction norms and payment rates for the specific manufacture or inaccordance with the staff-payment tables, if they work in the field of management or sanitary service. The production norms of the patients may bereduced if the Head of the health establishment deems it necessary.

2. Patients in Work therapy, who prior to admission have not been insured for anyinsurance cases should be insured for labour accidents. Patients who have beeninsured for any insurance case have their insurances kept on in the course of the Work therapy. The insurance procedure, the cases and the terms for payingindemnities for temporary incapacitation and other insured cases are settled byRegulations after article 110.

3. Patients to whom indemnities are paid for temporary incapacitation receive an

encouragement, too, for their work participation.

Article 109

For the sake of organising the patients’ Work therapy in the farms andworkshops, a percent of health workers, working on production norms, may beemployed, after a permission is given by the Ministry of public Health, or theMinistry of Finance or the Ministry of Labour and Social Welfare.

Article 110

The Minister of Public Health, The Chairman of the Bulgarian Trade Unions’Central Council and the Minister of Labour and Social Welfare issueRegulations for the application of this part.



APPENDIX IIIConstitution of Republic of Bulgaria (1991)

Article 5

1. The constitution is a supreme law and no other law can contradict it.

4. The international contracts ratified in constitutional way, published and comeinto force for Republic of Bulgaria, are a part of internal law of the country. Theyhave priority over such rules and regulations of internal legislation whichcontradict them.

Article 28

Everybody has a right of life. Violation of human’s life is punished as gravestcrime.

Article 29

1. Nobody can be subjected to torture, to cruel, inhuman or humiliating treatment,neither to a forced assimilation.

2. Nobody can be subjected to medical, scientific or other experiments without hiswritten consent.

Article 30

1. Everybody has the right of personal liberty and immunity.

Article 32

1. The personal life of citizens is inviolable. Everyone has the right of defenceagainst illegal intervention in his personal and family life and against aggressionon his honour, dignity and good name.

2. Nobody can be photographed, filmed, registered or subjected to other similar actions without his consent or in spite of his expressed disagreement, except incases foreseen provided by the law.

Article 34

1. The freedom and privacy of correspondence and other communications aresacred.

2. Exceptions to this rule are admitted with permission of the judicial authorities,when it is necessary to reveal or avert severe crimes.

Article 42

1. Citizens aged over 18, excluding those considered legally completely incapableby court and persons convicted to serve a prison sentence, have the right to



vote for government and local authorities and to take part in referendums.

Article 48

1. The citizens have the right to work. It is the concern of the state to createconditions for realisation of this right.

4. Nobody can be forced to do compulsory work.

Article 51

1. The citizens have the right to social insurance and support.

3. Old people who have no relatives and cannot provide for themselves from their property, as well as persons with physical or mental disorders are under specialprotection by the state and society.

Article 52

1. The citizens have the right to health insurance guaranteeing them accessiblemedical care and medical service free of charge under conditions and order arranged by the law.

4. Nobody can be forced to compulsory treatment or sanity measures, except incases foreseen by the law.

Article 56

Every citizen has a right of defence when his rights or legal interests aremenaced or violated. To (ensure) this he can appear with a defender.

Article 57

1. The basic rights of the citizen are irrevocable.

2. It is not admissible to abuse powers, or to use them if this will impair the rights or legal interests of others.

3. On declaring a war, a military or other extraordinary situation, temporarily can belimited by a law the exercise of some rights of the citizens, excluding theprovisions under Articles, 28, 29, 31 (1,2,3), 32 (1) and 37.



APPENDIX IV

Schedule of Meetings and Visits

Tuesday 24.02.98

Evening Meeting with Amelia Nikolova, President of the Neuroscience and Behaviour Research Foundation and Alia Veder , Director of the NBF .

Wednesday 25.02.98

AM Meeting with Rumen Ratchev from the proposed National Mental Health Association. Also present was his Secretary and Public RelationsOfficer

PM Meeting with Boris Boyadjiev, President of the Bulgarian Psychiatric

Association and Director of the National Centre for Interdisciplinary Human Studies. Also present was Vesselka Christova from the BPA

PM Video Presentation and Discussion with Dimiter Stamenov and 2psychology student volunteers from the Mental Health Society of Sofia.This meeting was also attended by a group of volunteer psychiatrists andsome student volunteers who run an emergency ‘phone-in service in Sofiacalled Trust Line. In addition I met Katarina Dimova who works with theMiloserdie Foundation.

Thursday 26.02.98

AM Meeting with Boyan Strahilov who is a member of the Bulgarian Brief Therapists’ Society and is involved with the running of a Day CentreService at Sofia Hospital along with Georgi Nestorov Arsenov andDiana Velkova.

PM Meeting with various Heads of Department from the Centre of Hygiene inSofia, including Associate Professors Vassil Pisev, Donka Baykova andBlagoy Yordanov . The Departments involved in this meeting areconcerned with children at risk and their work concentrates particularly onthe areas of Child Hygiene and Nutrition. Also present at this meetingwere Amelia Nikolova and Alia Veder .

PM Meeting with Nicolai Butorin, a project worker with the Mental HealthSociety of Sofia.

Friday 27.02.98



AM Meeting with members of the Mental Health Society of Sofia. We metwith Rumen Petrov , President of the MHSS and other members of MHSS .

PM Travelled to Targovishte in the west of Bulgaria. Ongoing meetings withEmilia Dimitrova, a psychiatrist at Targovishte hospital and President of the “Mental Equilibrium” Association. I also met regularly with

Vesselka Vassileva, a child psychiatrist and President of the Mental Health Society of Targovishte.

Saturday 28.02.98

AM Meeting with some delegates attending a conference in Shumen, hostedby a large drug company (Janssen-Cilag) for psychiatric staff. We metwith Dr Jordanka Penkova and Dr Nikolova from an NGO in Shumencalled the Ex-Patients’ Club. Also present were the Administrative Headof Psychiatric Services at Shumen Hospital (I was unable to get his name)and a representative of Janssen-Cilag, Julian Zaimov , who is involved insome capacity with the, as yet un-registered Balkan Federation for Mental Health.

PM Visit of Psychiatric Unit on the outskirts of Shumen, attached to ShumenHospital. Met with the duty-nurse and with some patients.

Evening Meeting with users and workers from the Mental Health Society of Targovishte and the “Mental Equilibrium” Association. In addition tothe presidents of both societies, Dr Vesselka Vassileva and Dr EmiliaDimitrova, about 14 other members attended the meeting.

Sunday 01.03.98

AM Further meetings with staff from Targovishte Hospital including Dr IvanTianev who is involved with an organisation called the Life Foundation,in Targovishte.

PM Returned to Sofia.

Evening Further meeting with Alia Veder from the Neuroscience and Behaviour Research Foundation and the Network of Bulgarian Mental Health

NGOs.

Monday 02.03.98 AM Follow up meeting with Boris Boyadjiev and Vesselka Christova from

the Bulgarian Psychiatric Association

Tuesday 03.03.98



AM Meeting with the Chief Advisor to the Minister of Social Affairs (withparticular responsibility for NGOs), Mario Sarbinov

PM Meeting with Todor Mindilikov the Executive Director of the BudninaFoundation” .



APPENDIX V

References

Bulgaria Business Guide - Foreign Investment Agency

NGO Directory (of organisations working in mental health in Central and EasternEurope) - Penumbra International & Romanian League for Mental Health

EURO WHO (European Region) Report

“Toward the Liberation of Mental Health” - Dr Toma Tomov & The Bulgarian Psychiatric Association, 1994

Data from the Office of the Head Prosecutor, Sofia, Bulgaria

“Voluntariness: Inconsistency in Law and Psychiatric Practice in Bulgaria” - paper presentation by Boris Boyadjiev World Congress of Psychiatry, Madrid, 1996

Reports from edition number 5-6, 1997 of the publication “Les Droits de l’Homme sandFrontières”

Public Health Act (1973) of the Republic of Bulgaria

Constitution of the Republic of Bulgaria (1991)

Penal Code of the Republic of Bulgaria (1968)

Bulgarian Ministry of Public Health, State Gazette no 58 (July 1981): Instruction no 1on the Duties of Health Authorities Regarding Compulsory Admission to PsychiatricHospitals

Documents

Bulgaria A Country Report