HEALTH SINCE 1945: INSTITUTIONALIZATION PERIOD, PART 5
From: ***. Bulgaria's Road to "Health for All". Sofia: Publishing House at the Medical Academy, 1987.
The adoption of the goal of "Health for All" by the year 2000 from the member states of the World Health Organization /WHO/ in May 1977 became a turning point in its history and an event with profound long-term implications for the health and social policies of all nations. The challenge of "the attainment by all citizens of the world by the year 2000 of a level of health, that, would enable them to lead socially and economically productive lives" has given birth to a programme of peaceful cooperation and competition between countries of different social and political systems, small or large, developing or developed. In this, the WHO and its member states have set an example of how different interests, ideologies and political systems can work together in the name of an attainable goal promising well-being and better quality of life to the millions of ordinary people throughout the world.
The past ten years have witnessed some significant progress towards the achievement of this objective, as well as, many difficulties and obstacles. The "International Conference of Primary Health Care", which, took place in Alma Ata, USSR, in 1978 was a major early landmark in the right direction. Under the leadership of Dr. Halfdan Mahler, the Director General of WHO and a dedicated architect of the "Health for All" movement, the WHO secretariat has developed an orderly conceptual and practical system of methodological instruments and guidelines in support of the efforts of the member states. Many countries have succeeded in accomplishing profound structural reforms in their national health care systems and in re-orienting a considerable part of their human, material and other resources towards providing efficient and accessible primary health care, preventing socially significant disease and other health problems, and ensuring social equity in health care. Other countries, however, have experienced serious economic difficulties, often aggravated by natural disasters, hostilities, dependence inherited from the colonial past and lack of a developed infrastructure. But irrespective of such divergences and of the uneven rate of progress towards the common goal, "Health for All" has become a global task, a system of new values and a set of specific strategies within the framework of world health during the last quarter of the XX century.
Bulgarian health workers and the entire Bulgarian society, as well as, the health workers and the peoples of many other countries, are clearly aware of the fact that the achievement of "Health for All" could be significantly accelerated if the world could free itself of the burden of the colossal expenditures on arms. The mere existence of nuclear arsenals having the potential of a global destruction puts in question not only the achievements of "Health for All", but, the very survival of humankind.
The realization of the most human goals of "Health for All", its accompanying system of values and the corresponding strategies, are in full concordance with the ideology and the objectives of the social development of the People's Republic of Bulgaria /PRB/. For forty years the principles underlying Bulgarian socialist health care and social policy have been consonant with the fundamental requirements proclaimed by the WHO in 1977, i.e. accessibility of health care, social equity in the allocation of health resources, government and community responsibility for the health of all citizens and priority of prevention.
At present, an intensive social and economic reorganization is taking place in PRB. It is related to real needs arising in the process of building up a mature socialist society. In the course of this reorganization utmost priority is given to the satisfaction of human needs and to providing the optimal conditions for a harmonious development of the individual person. One of the important prerequisites to the attainment of these objectives is the improvement of the health state of the population, the eradication or control of some diseases, the significant decrease in the impairments and disabilities resulting from other diseases and the achievement of a harmony between man and his environment.
The intensive international exchange of information and experience and the programme documents and methodological tools produced by WHO, have found a vivid resonance among Bulgarian health workers and health planners, the public opinion and the government. Since 1977, national programmes dealing with key health and social problems have been drafted and adopted in accordance with the "Health for All" principles. Naturally, the time has now come for an overall review of the current state, trends and future projects in the main areas of public health and social development, which, will determine the attainment of the "Health for All" objectives.
The present document - Bulgaria's Road to "Health for All" - has been prepared in response to the unanimous decision of WHO member states for developing national strategies and plans of action in accordance with global and regional "Health for All" strategies. Each section of the paper contains a brief analysis of a particular problem, an outline of the approaches to its solution and a statement of the intermediate and final targets. It is foreseen to set up a Coordination Council /CC/, which, will monitor the implementation of the separate activities within the national strategy and coordinate the work of all the participants in the process. The CC will analyze annually the progress towards the accomplishment of the specific tasks according to an agreed timetable. An overall evaluation of the strategy will be carried out biennially by the "Collegium of the Ministry of Health" and the "Presidium of the Medical Academy". The results of these interim evaluations will be reported to the CC.
2. SYNOPSIS OF OBJECTIVES AND TARGETS
Promotion of healthy lifestyles
|Reduction of alcohol consumption|
Promotion of environmental health
Rearing a healthy and harmoniously developed young generation
Prevention and control of socially significant disease and related health problems
Biomedical science and technology: a prerequisite for achieving "Health for All"
Improving the organization and management of health care
Financial support of health care
Training and development of human resources
3. HEALTH POLICY OF THE PEOPLE'S REPUBLIC OF BULGARIA
The People's Republic of Bulgaria /area: 111 000 km2 and population: 8 949 618/ is one of the oldest countries in Europe. It was founded in year 681 and in the early Middle Ages became the cradle of the Slavonic script and a major focus of culture. Its stormy history passed through periods of flourishing and decline, through centuries long struggles for national independence and self government.
Already during the first years following the Liberation of the country from the Ottoman rule /in year 1878/, a project for the organization of a national health service was developed by Bulgarian physicians. The first health projects at the time were influenced by the advanced Russian community medicine, which, emphasized prevention and democracy. However, within the framework of the capitalist state, Bulgarian public health policies were subordinated to the interests of the ruling class and gradually yielded to the private capitalist enterprise. Under the conditions of the bourgeois state the solution of national health problems suffered serious neglect.
Immediately after the victory of the Socialist Revolution on 9 September 1944, the new People's government set itself the task to resolve the major problems of public health, which, had been aggravated by the conditions resulting from the Second World War. In that period the health indices for the nation showed high infant mortality rates and high prevalence of communicable diseases, such as, tuberculosis, diphtheria, typhoid fever, exanthematic typhus and malaria. Hospital services were inadequate and restricted to cities and big towns.
The Socialist Revolution proved a turning point in Bulgarian public health. The essence of the health policy of the People's government was phrased in brief by Georgi Dimitrov: "Health and working capacity are the most precious national wealth". According to the "Constitution of PRB", health is "a basic human right safeguarded and promoted by the state and the socialist society". After its establishment, the "Ministry of Health" was assigned the important task to overcome the shortcomings of bourgeois public health and to develop a new system of health promotion and protection.
The first step of the People's government towards the establishment of a new health care system was the putting into practice of the Leninist principles of socialist public health, i.e. to make highly qualified medical care available to the entire population free of charge; to promote prevention as the mainstream of public health; to integrate medical science with medical practice; and to ensure the participation of all the sectors of society and the people's organizations in the implementation of health measures.
The system for preventive and therapeutic care in Bulgaria at present is built up on the territorial principle /residential or occupational/. Its methodology emphasizes strongly the so-called dispensarization approach, i.e. the active medical follow-up of large groups of the population. A network of hygiene and epidemiological monitoring stations were established, as well as, a "State Sanitary Inspectorate". As of year 1951, all the citizens of the country were entitled to medical care free of charge.
A decisive impetus to the advance of public health was given by the "April Plenum of the Central Committee of the Bulgarian Communist Party" in 1956. The supreme principle underlying, what, became known as the April policy of the Party - "Everything in the name of man, everything for the welfare of man" - evolves from the ultimate goal of communism, to promote the free and harmonious development of everybody. This political position ensured a lasting and comprehensive support to public health and laid down the lines for its further development: better coverage with health care, concentration of resources and establishment of health facilities with improved diagnostic and therapeutic potential, promotion of medical science and technology, transfer of the best achievements in world health science and practice, etc.
Within the provision of the "Constitution of PRB", the access to free health care is guaranteed to everybody in Bulgaria. The comprehensive network of health facilities now includes 3851 outpatient and polyclinic services, 187 hospitals with a bed/population ratio of 93 hospital beds for a population of 10 000, 196 sanatoria, 1199 creches and nurseries, 167 social welfare homes, 4644 pharmacies, 29 hygiene and epidemiological inspectorates, etc. The number of health workers is over 190 000, including 25 665 physicians, 5745 stomatologists, 4209 pharmacists and over 84 000 mid-level health personnel. The annual number of outpatient medical contacts is over 86 million, of hospital admissions - over 2 million, of persons covered by medical follow-up care - over 4 million, etc.
Health care is being brought increasingly closer to the population by constantly strengthening the frontline of primary health care and emphasizing the coordinative role of the district physician. In the field of prevention the measures aiming at the improvement of the living environment become increasingly comprehensive and effective. The dynamic social and economic development, the rising standards of living and the involvement of the community are conductive to a constant improvement of the health status of the population. At present, the average life expectancy is over 71 years /versus 48.4 years in 1944/ and infant mortality has decreased to less than 15 per 1000 live births. Many communicable diseases have been eradicated and there is a trend towards a decrease in temporary and chronic disability; physical fitness and mental health, especially as concerns the younger generations, enjoy a high priority and the well-being of the entire population has been improved. It is foreseen to expand the principle of free medical care in the forthcoming years by providing all the essential drugs to those, who, need them free of charge. On a number of important health indicators the PRB ranks among the highly developed countries.
The advances in public health run in parallel with the progress of Bulgarian medical science. At the "Tenth Congress of the BCP", a new approach towards science and education was adopted, aiming at interlinking them more closely with social, economic and cultural development. The "October Plenum of the CC of the BCP" in 1971 set the task of reorienting science to socially relevant goals and integrating research with training and practical work at all the institutions of higher education. As a result, the Medical Academy was established in 1972. It was entrusted with the following tasks:
further concentration of the scientific potential in biomedical research and its integration with medical education and medical care;
integrated management of research, the development of science, medical technology and higher education;
promotion of international collaboration;
The establishment of the Medical Academy led to an efficient concentration of cadres and resources, and, to their orientation towards key health problems. Health research was pursued not only within the Medical Academy, but, also in collaboration with the Bulgarian Academy of Sciences, the Academy of Agriculture and other institutions.
During the past decade 25 biomedical research institutes, 5 higher medical institutes /medical schools/ and 3 centres for applied research and production were established. The Medical Academy thus became a powerful research, diagnostic and therapeutic complex, which, also has the important function of training highly skilled health workers.
Much of the research potential available at the Medical Academy is engaged in the development of new biomedical technologies, including original pharmaceutical products, advanced medical electronic equipment and other items produced to meet the local needs or for export in both developed countries and developing ones. More than 1600 technological inventions and innovations have been registered by the Medical Academy in the past 5 years. A number of scientific achievements have already been put into practice.
The resolutions of February 1985 and January 1986 Plenums of the CC of the BCP emphasized, that, the further development of Bulgarian society would have to be based on the accelerated advance of science and technology and the application of their products in all spheres of life. The "Thirteenth Congress of the BCP", laid the foundations of a new important stage in the social development of Bulgaria by adopting a national long-term strategy for scientific and technological progress, developed under the guidance of Todor Zhivkov - Secretary General of the CC of the BCP.
The strategy envisages a profound reorganization of science, with the aim of overcoming existing flaws in certain areas and mobilizing the creative potential of the nation. The accelerated implementation of scientific and technological advances and the transfer of leading world expertise, should provide the basis and conditions for a new stage in the promotion of health, prevention of diseases and the overall improvement of the work capacity and quality of life of people. The most important objective is to qualitatively upgrade health care, and, by means of a selective reorganization to direct all the efforts towards the solution of the most significant health problems. Bulgarian society has reached now a stage, when, it becomes possible to carry out a scientific and technological revolution in public health at an accelerated pace. Research into the molecular basis and mechanisms of heredity, of carcinogenesis, of hormonal and central nervous control over the physiological functions, hold out unexpected opportunities for preventing and treating disease and for promoting health. In due cognizance of the key importance of mental health and human behavior and of the role of the brain in the homeostasis of the organism, special attention and resources have been given to an integrated programme of neuroscience and behavioral science research.
In the light of this, the control of socially significant diseases comes to the fore. Due to the high morbidity, mortality and disability and the serious social, economic and psychological impact of cardiovascular, cerebrovascular and respiratory diseases, malignant neoplasms, injuries, diabetes and mental disorders - these conditions have been selected as the targets of a major national programme for primary prevention, treatment and rehabilitation. The programme includes a variety of social, behavioral and medical measures and specifies clearly the responsibilities for their implementation both within and outside the health care system. Dyspensarization will remain a key approach and according to the plan 65 per cent of the population would be covered by active medical follow-up by year 1990.
At this stage it is particularly important to shift the focus from a preoccupation with the treatment of disease, only, towards health promotion and disease prevention, in order to maximize the chances of all the people to enjoy lives free from disease and disability at the highest possible levels of physical fitness and mental activity that are commensurate with their age. In accordance with the Constitution of the WHO, which, emphasizes that "health is a state of complete physical, mental and social well-being and not merely the absence of disease or disability", the activities of the health system will increasingly be directed not only towards the persons who are ill, but, also towards the healthy. An example of the new measures within this comprehensive approach to the promotion of health is the establishment of the so-called "health workshops" in the industrial enterprises and organizations. There is now in Bulgaria a growing awareness, that, in view of the multiple determination of health programmes for health promotion and disease prevention prompt actions by all the state, economic and social bodies and organizations; public health is now clearly seen as a national cause. According to this new approach, health care must begin with health education of the population and participation by the people is required in all programmes dealing with prevention, treatment, rehabilitation and social assistance.
More than forty years have elapsed since the first People's government announced in its programme the strategy for the protection of the people's health. During that period of time fundamental changes have taken place in Bulgaria. The development of the health care system has paralleled the overall economic and cultural advance of the country. In the decades ahead, Bulgarian health workers and the nation as a whole, face major new tasks and challenges clearly outlined in the historic decisions of the "Thirteen Congress of the BCP". These decisions have set the signposts of Bulgaria's road to "Health for All" by the year 2000.
4. CONTEMPORARY STRUCTURE OF THE FRONTLINE OF HEALTH CARE IN BULGARIA
Editor's note: This chapter, essentially, covers the same material given before in chapter 18 from our exposition: sketch
5. PROMOTION OF HEALTHY LIFESTYLES
In the course of implementation of the System for Balanced Nutrition on a national scale, the following objectives will be pursued:
By the year 2000, the prevalence of obesity /expressed as overweight exceeding by 20 per cent or more the optimal weight/ should be reduced to less than 10 per cent in the male population, and, to less than 20 per cent in the female population;
By the year 2000, cholesterol content in the blood serum should be reduced to under 200 mg/100 ml or 5.17 mmol/l for the age groups 15 to 64 age, and, to under 150 mg/100 ml or 3.87 mmol/l for children up to 14 years of age;
By the year 2000, the mean consumption of table salt per capita should be reduced to no more than 6-8 g sodium chloride per day, with, a trend towards a further decrease to 4-6 g per day;
The nutrition education of the population should be improved, so that, by the year 1990 no less than 40 per cent of the people from all ages would have adequate knowledge about the diet appropriate to them; by the year 2000 this percentage should be at least 60, as ascertained by questionnaire surveys;
By the year 2000, the consumption of animal fats should be reduced by 30 per cent, and, that of sugar and sugar products - by 35 per cent; at the same time, the consumption of fresh and frozen vegetables, fruit and fish should at least double and the production of vegetable and fruit juices and mousses additionally enriched with calcium and potassium should be substantially increased;
From 1988 on, obligatory labeling of foodstuffs should be introduced, in order to inform the consumers about their nutritive and biological value; the concentration of sodium chloride should be indicated on the packing of commercially available table salt. By 1987, amendments to the Bulgarian State Standards for processed and semi-processed foods should be initiated, in order to make them consistent with up-to-date scientific norms of balanced nutrition;
The most important objectives are as follows:
The number of curricular and extracurricular classes for physical activity of schoolchildren should be increased: for grades I to III up to 13-14 hours weekly; for grades IV to VII up to 12-13 hours weekly; for grades VIII to XII up to 8-9 hours weekly;
There should be at least six obligatory days for walking tours in each school term and a year round mountain camping base should be provided for about 5000 schoolchildren by 1988;
By the year 1990, the proportion of the adult population in age groups 18 to 65 years, who, are engaged in adequate physical fitness activities three or more times a week should reach 50 per cent, and, by year 2000 - 80 per cent;
By the year 1990, no less than 60 per cent, and, by the year 2000 no less than 90 per cent of the adult population in age groups 18 to 65 years should be acquainted - theoretically and practically - with the scientific norms of optimal physical fitness and activity;
The following specific objectives will be pursued:
By the year 1990, the sales of cigarettes should be reduced by 20 per cent as compared with year 1985, and, by the year 2000 - by further 30 per cent as compared with 1990;
The proportion of smokers in the population should be reduced from 42 per cent in year 1985, to 35 per cent by year 1990, and, to 25 per cent by year 2000;
By the year 1990, the proportion of schoolchildren from 12 to 18 years of age who learn the smoking habit should be reduced to under 5 per cent, and, by the year 2000 - to under 1 per cent;
By the year 1990, no less than 75 per cent of the adult population should be able to specify the diseases related to smoking /as ascertained by questionnaire surveys/; by the year 2000, the proportion of the informed population should be 95 per cent;
From 1988 on, the contents of the obligatory warning notice on the packets of cigarettes about the hazardous effects of smoking should be amended to include information on the nicotine and tar content and on the amount of carbon monoxide released in the course of smoking;
From 1988 on, short term courses on behavioral therapy aiming at smoking cessation and overcoming the smoking habit should be available at the outpatient and polyclinic units and in the "health workshops" attached to industrial enterprises; such courses should be organized with the support of the relevant research institutions and the Trade Unions; in order to provide support to all the smokers who have decided to give up smoking, mutual aid clubs or groups for ex-smokers should be organized at their place of work;
By the year 1990, the smoking habit among all physicians and teachers should be eradicated on a voluntary basis;
Reduction of alcohol consumption
The most important objectives are:
A decrease of mean alcohol consumption per capita from 7.32 l absolute alcohol in 1985, to less than 5.0 l in 1990 and less than 4.0 l in 2000;
By the year 2000, a decrease should be achieved by at least one-third in the incidence of alcohol related liver disease; the incidence of alcohol related disorders such as delirium tremens, hallucinosis, Korsakoff's psychosis and fetal alcoholic syndrome should be reduced to a level that would make it possible to regard them as clinical rarities;
By the year 2000, the proportion of traffic accidents due to alcohol use should be reduced to under 50 per cent of all accidents;
By the year 2000, the number of people of specialized antialcoholic treatment should be reduced by 50 per cent as compared with their number in 1985;
6. PROMOTION OF ENVIRONMENTAL HEALTH
Measures are adopted by the Committee for the Protection of the Environment:
By the end of 1990, at least 2 or 3 settlement systems, and, at least 25 towns and villages in each province of the country should be developed into models of sanitation and hygiene;
By the end of 1990, 55 per cent of the industrial enterprises /encompassing no less than 70 per cent of the industrial workforce/ should meet the requirements of hygienic regulation; by the year 2000, their proportion should exceed 90 per cent;
7. REARING A HEALTHY AND HARMONIOUSLY DEVELOPED YOUNG GENERATION
The basic approaches towards the achievement of this objective are as follows:
By the year 2000, the rate of newborns with low birth weight /less than 2500 g/ should be reduced to under 6 per cent;
By the year 2000, the incidence of congenital malformation and anomalies, especially those relating to the neural tube and the cardiovascular system, should be reduced to 2.5 per 1000 live births;
Perinatal mortality from all causes should decrease from 12.3 per 1000 live births in 1985, to 11 per 1000 live births in 1990 and to less than 8 per 1000 live births in 2000;
A decrease in post-neonatal mortality rate /the mortality of live born children who die at an age from 1 month to 1 year/ should be attained, from 7.1 per 1000 live births in 1985, to 5.0 per 1000 live births in 1990 and to less than 3.5 per 1000 live births in 2000;
The stillbirth rate should decrease from 6.6 per 1000 births in 1985, to 6.0 per 1000 births in 1990 and to less than 4.0 per 1000 births in 2000;
By the year 1990, the infant mortality rates should be reduced to less than 11 per 1000 live births, and, to less than 9 per 1000 live births by the year 2000, with a trend towards further decrease;
By the year 1990, no less than 80 per cent and by the year 2000, no less than 90 per cent of the pregnant woman should be thoroughly familiar with the risk factors that may affect fetal and infant health;
By the year 2000, the proportion of parentless children, who, are adopted or placed with foster families after a stay in an institution of no more than one year should increase to 85-90 per cent;
8. PREVENTION AND CONTROL OF SOCIALLY SIGNIFICANT DISEASES AND RELATED HEALTH PROBLEMS
A National Programme for the Prevention and Control of Socially Significant Diseases in Bulgaria has been developed and adopted:
Cardiovascular diseases: The national objective is, by the year 2000 to achieve a decrease in the mortality rate from ischemic heart disease of 24 per cent as compared to 1985, i.e. to reduce it to 190 per 100 000 total population /all age groups/, and, to 66 per 100 000 total population for the age groups 45-54; to decrease the mortality rate from cerebrovascular disease by 30.2 per cent compared to 1985, i.e. to reduce it to 184 per 100 000 total population;
Malignant neoplasms: With a mortality rate of 164.9 per 100 000 total population /1985/ malignant neoplasms rank second among the main causes of death in the entire population /all age groups/; and with a mortality rate of 384 per 100 000 total population are the leading cause of death for the age groups over 55 years; it is expected that the implementation of this strategy will result by the year 2000 a decrease in cancer mortality rate of about 16 per cent as compared to 1985, i.e. will be reduced to 138 per 100 000 total population /all age groups/;
Respiratory diseases: With a mortality rate of 92.3 per 100 000 total population, respiratory diseases account for about 45 per cent of registered disease prevalence; it can be expected that the successful implementation of measures will result in a decrease by the year 2000 of the prevalence and mortality of respiratory diseases by about 25-30 per cent as compared to 1985;
Accidents and injuries: In 1985 the mortality rate from accidents and injuries in Bulgaria was 63.5 per 100 000 total population;
Mental disorders: About 1 per cent of the total population /all age groups/ is in need of therapeutic and rehabilitative care because of chronic or recurrent mental disorders;
Infectious diseases: During 1981-85 the incidence of all infectious diseases /excluding influenza and acute respiratory diseases/ has been decreases by 21.9 per cent; the incidence of infectious intestinal diseases by 31.6 per cent; and the incidence of infectious respiratory diseases by 16.8 per cent, as compared with the previous five year period /1976-1980/;
9. BIOMEDICAL SCIENCE AND TECHNOLOGY: A PREREQUISITE FOR ACHIEVING "HEALTH FOR ALL"
The general aim of health research and the development of new technologies during the following 10-15 years will be to ensure the scientific back-up to the Bulgarian strategy for attaining "Health of All". This presupposes a priority development of those branches and trends of science which will:
Guarantee the development and implementation of technologies directly serving the programmes for promotion of healthy lifestyles, control of the socially significant diseases, health protection of children and adolescents, environmental protection and rising the quality and accessibility of health care;
Increase knowledge about the patterns and trends of morbidity and health in the community, with, a view to making predictions, identifying needs and improving health care management;
10. IMPROVING THE ORGANIZATION AND MANAGEMENT OF HEALTH CARE
The further development of public health in Bulgaria will require certain decisive improvements of the organization and the system of management of health care. The new requirements arise naturally in the course of construction of a mature socialist society, namely:
Joint management of the health services by the state and the community;
Strengthening the role of the Ministry of Health;
Strengthening the role of the Medical Academy;
11. FINANCIAL SUPPORT OF HEALTH CARE
The global trend of rising health care costs also has its effects on health care support in Bulgaria. This is evident from the higher rate of increase of health expenditures in comparison to the growth of national income, viz:
While during the period 1970-1980 the average annual rate of national income growth was 6.9 % and that of the government budget 8.8 %, health expenditures grew at an annual rate of 10.9 %;
In 1985 the health care expenditures amounted to 6.1 % of the national income;
12. TRAINING AND DEVELOPMENT OF HUMAN RESOURCES
The most important objectives, as viewed by the national strategy, are as follows:
By year 1990, the number of doctors will increase to 28 235 or 31.3 per 10 000 citizens; the number of dentists will be 6228 or 6.9 per 10 000; and that of the nursing staff will be 94 223 or 104.6 per 10 000 citizens;
By year 1990, the ratio between doctors and dentists on one hand, and, nursing or supporting medical personnel on the other - will improve, and from 1:2.56 at present will reach 1:2.62 with a tendency towards further improvement up to 1:3.50, by the year 2000;
By year 2000, the number of higher medical staff is expected to be 31 200, thus, reaching a coverage of 33.7 doctors per 10 000 population; no less than 48 % of the net increase in the number of doctors will be absorbed by the "front line" of health care, and, it is expected that by the year 2000 one-half of all doctors will work in primary health care;
13. INTERNATIONAL COOPERATION
Multilateral cooperation in health is regarded by Bulgaria as being of key importance to the attainment of "Health for All". New proposals will be developed for its qualitative upgrading, both, within the framework of CMEA and WHO programmes:
The medium term Collaborative Programme between Bulgaria and WHO will focus increasingly during the coming years on the specific European targets for attaining "Health for All" by the year 2000;
The Bulgarian institutes designated as WHO Collaborating Centres will play the principal technical role in the implementation of joint programmes and activities with the WHO Regional Office for Europe and the WHO Headquarters in Geneva;
The participation of the Bulgarian research institutes in the conception and implementation of WHO programmes will be expanded and steps will be undertaken for the establishment of further WHO collaborating and reference centres in this country;
14. CONCLUDING NOTES
The present document has been prepared by a working group under the guidance of Academician Professor A. Maleev, Associated Professor A. Jablensky and Associated Professor L. Ivanov