Report No: AUS0002814 . Bulgaria Disability System and Policy: A Comprehensive Review Aleksandra Posarac, Jerome Bickenbach, Marijana Jasarevic, and Viktorija Vasiljeva-Gringiene in collaboration with Yordan Dimitrov, Pavlina Petrova, Pavel Dimov, Miryana Siriyski, Vera Veleva, Ivan Karagyozov and Angel Angelov 2022 . SPL . W . © 2022 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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Table of Contents Acknowledgements................................................................................................................................. 1 Executive Summary................................................................................................................................. 2 Chapter 1: Disability at a Glance in Bulgaria ......................................................................................... 18 1.1. Disability prevalence and trends ............................................................................................... 18 1.2. Key messages ............................................................................................................................. 29 Chapter 2: Disability policy and system: legal and institutional framework ........................................ 30 2.1. Summary of key legal provisions ............................................................................................... 30 2.2 Institutional structure for disability system and policy .............................................................. 35 2.3 Key messages .............................................................................................................................. 52 Chapter 3: Disability and work capacity assessment and certification In Bulgaria .............................. 56 3.1. Introduction ............................................................................................................................... 56 3.2. Institutional Framework for Work Capacity and Disability Assessment ................................... 57 3.3. Data on temporary and permanent disability and reduced capacity for work ......................... 60 3.4. Medical expertise procedures ................................................................................................... 61 3.5. Medical expertise of disability or reduced work capacity – methodology and instrumentation .......................................................................................................................................................... 67 3.6. Redress system: Appeals and objections................................................................................... 68 3.7. Key messages ............................................................................................................................. 70 3.8. Annex 1: Institutional framework .............................................................................................. 73 Chapter 4: Complex individual needs assessment of persons with disabilities in Bulgaria.................. 75 4.1. Development of complex individual needs assessment in Bulgaria.......................................... 75 4.2. Individual needs assessment in the Persons with Disabilities Act ............................................ 77 4.3. Assessment information and forms........................................................................................... 78 4.4. Domains of support ................................................................................................................... 82 4.5. Individual needs assessment administrative process................................................................ 83 4.6. Data on individual needs assessments ...................................................................................... 87 4.7. Administrative Process of the individual needs assessment under the Social Service Act (SSA) .......................................................................................................................................................... 90 Chapter 5: Public measures to support persons with disabilities......................................................... 96 5.1. Disability specific support measures ......................................................................................... 96 5.2. Public spending on support measures specific to persons with disabilities ............................. 97 5.3 A snapshot of programs, beneficiaries, and spending ............................................................. 100 5.4 Key messages ............................................................................................................................ 117 Chapter 6: Labor market inclusion of persons with disabilities .......................................................... 121 6.1. Statistics on labor market participation of persons with disabilities ...................................... 121 6.2. Regulatory framework for labor market policies for persons with disabilities ....................... 124 6.3. Active Labor Market Programs for Persons with Disabilities .................................................. 127 6.5. Annex 2: Description of active labor market programs for persons with disabilities ............ 142 Chapter 7: Disability information and data management systems .................................................... 147 7.1 Information System for the Medical Expertise......................................................................... 147 7.2 Integrated Information System at the Agency for Social Assistance........................................ 152 7.3 Information system of the Agency for People with Disabilities ............................................... 158 7.4 Key Messages............................................................................................................................ 160 ANNEX ................................................................................................................................................. 165 Annex 1: Disability Data ................................................................................................................. 165 Annex 2: Legal Framework ............................................................................................................. 180 Annex 3: List of Legal Acts Pertaining to Disability with Active Links ............................................. 202 Annex 4: Specific Programs to support Persons with Disabilities .................................................. 205 Annex 5: Persons with Disabilities Act Individual needs assessment templates (informal translation from Bulgarian into English) ........................................................................................................... 236 References .......................................................................................................................................... 262 List of Figures Figure 1.1: Stable trend: persons with permanent, formally certified disability in Bulgaria 2015-2019 .............................................................................................................................................................. 19 Figure 1.2: The majority of persons with disabilities are over 65 years of age - Persons with disabilities by age groups 2017-2019.................................................................................................... 19 Figure 1.3: Disability prevalence by age groups in 2019 (the prevalence calculated as the share of persons formally certified as having a disability by medical expertise - >50 percent relative to the total population) ................................................................................................................................... 20 Figure 1.4: Severity of disability increases with age - Disability by age and severity in 2019 .............. 21 Figure 1.5: Severe and very severe disability dominate - Persons with disability by severity of disability 2017-2019 .............................................................................................................................. 21 Figure 1.6: Persons 16 and over who have received expert decision on permanent disability 2010- 2019, by age groups .............................................................................................................................. 22 Figure 1.7: Percentage shares of persons 16 and over who have received expert decision on permanent disability 2010-2019, by age groups .................................................................................. 23 Figure 1.8: Persons 16 and over who have received expert decision on permanent disability by the assigned degree (in %) of disability in 2010 .......................................................................................... 24 Figure 1.9: Persons 16 and over who have received expert decision on permanent disability by the assigned degree (%) of disability in 2019.............................................................................................. 24 Figure 1.10: Persons 16 and over having received expert decision for permanent disability for the first time by main groups of diseases in 2010 and 2019) ..................................................................... 25 Figure 1.11: Persons 16 and over having received expert decision for permanent disability for the first time by main groups of diseases and severity of disability in 2019 .............................................. 25 Figure 1.12: Persons self-reporting long-standing limitations in usual activities due to health problems, by country and by severity .................................................................................................. 27 Figure 1. 13: Persons 16 years of age and over self-reporting long standing limitations in usual activities due to health problems in Bulgaria and EU-27 2014-2019 ................................................... 28 Figure 1.14: EU SILC and administrative data on disability in Bulgaria, 2019....................................... 28 Figure 2.1: Main bodies responsible for the development, regulation, implementation, coordination and monitoring of disability policies in Bulgaria ................................................................................... 36 Figure 2.2: Government agencies responsible for disability determination and provision of disability related benefits and services in Bulgaria .............................................................................................. 37 Figure 2.3: The National Council for Persons with Disabilities structure ............................................. 38 Figure 2.4: The Monitoring Committee structure ................................................................................ 39 Figure 2.5: Ministry of Labor and Social Policy organizational structure ............................................. 42 Figure 2.6: The Social Assistance Agency organizational structure ...................................................... 45 Figure 2.7: Assessment of individual needs in Bulgaria ........................................................................ 46 Figure 2.8: Territorial Medical Expert Commission (TMEC) structure .................................................. 50 Figure 2.9: The National Medical Expert Commission structure .......................................................... 51 Figure 3.1: Medical assessment for permanent disability and reduced work capacity: applications and medical expert decisions 2016-2019 ............................................................................................. 61 Figure 3.2: Steps for medical expertise of the type and degree of permanently reduced work capacity/disability ................................................................................................................................. 66 Figure 3.3: Steps for appealing disability or reduced work capacity decision ...................................... 69 Figure 3.4: Disability appeals and revoked decisions (2017-2020) ....................................................... 70 Figure 4.1: PDA Individual Needs Assessment administrative process flow chart ............................... 84 Figure 5.1: Public expenditure on social protection benefits in Europe 2019...................................... 97 Figure 5.2: Public expenditure on disability benefits as % of GDP in EU 2019 ..................................... 98 Figure 5.3: Spending on disability benefits as % of total social protection spending in EU in 2019 .... 98 Figure 6.1: Number of persons with disabilities employed in ALMPs implemented by NEA……………130 Figure 7.1: Social Assistance Agency Functional Subsystems ............................................................. 153 Figure 7.2: Social Assistance Agency – Individual Data Model ........................................................... 153 Figure 7.3: SAA ISI – Logical Architecture ........................................................................................... 154 Figure 7.4: SAA – Administrative process and data flow .................................................................... 156 List of Tables Table 1.1: Applications for and completed medical expertise cases 2016-2019 (permanent disability) .............................................................................................................................................................. 22 Table 1.2: Distribution of persons by self-reported long-standing limitations in usual activities due to health problems, by sex, 2019 .............................................................................................................. 26 Table 2.1: Bulgaria: Mapping legal and institutional framework ......................................................... 52 Table 4.1: An extract from the Social Worker Form ............................................................................. 81 Table 4.2: An extract from the Self-Assessment Form ........................................................................ 82 Table 4.3: Applicants and approved applications for INA by the type of requested benefit ............... 87 Table 4.4: Approved adult (18 and older) users of personal assistance, by age groups and districts compared with district population up to 29.02.2020 ........................................................................... 88 Table 4.5: Approved adult (18 years of age and older) users of personal assistance, by age groups and districts compared with district population up to 29.02.2020, shares in % of total ..................... 89 Table 4.6: SAA expenditure 2019 .......................................................................................................... 91 Table 4. 7: SAA expenditure on the budget program Integration of persons with disabilities and on the individual needs assessment in 2019 ............................................................................................. 91 Table 5.1: Expenditure on social protection benefits by function 2019 ............................................... 99 Table 5.2: Monthly family allowance for children with disabilities, beneficiaries and expenditure 2017-2019 ........................................................................................................................................... 101 Table 5.3 (1): Disability pensions in Bulgaria: beneficiaries, average pension, and expenditure 2019 ............................................................................................................................................................ 103 Table 5.4 (2): Disability pensions in Bulgaria: beneficiaries, average pension, and expenditure 2021 ............................................................................................................................................................ 104 Table 5.5: Disability pension supplement for assistance by other people – recipients and expenditure 2018 – 2021 ........................................................................................................................................ 105 Table 5.6: Tax reduction for persons with disabilities ........................................................................ 106 Table 5.7: Beneficiaries and total amount of tax reduction for parents of children with disabilities 106 Table 5.8: Monthly financial assistance to persons with disabilities –recipients per month and annual expenditures 2019 .............................................................................................................................. 107 Table 5.9: Targeted financial support to persons with disabilities - recipients and expenditure 2017- 2019) ................................................................................................................................................... 108 Table 5.10: Targeted support for technology, devices, facilities and medical equipment and expenditure 2017-2019 – recipients and expenditure ....................................................................... 109 Table 5.11: Services for children with disabilities, users 2017-2019 .................................................. 112 Table 5.12: Social services for adults with disabilities, users 2017-2019 ........................................... 113 Table 5.13: Assistants to persons with disabilities, beneficiaries and expenditure 2017-2019 ......... 116 Table 5.14: Personal assistance to persons with disabilities – users and expenditure ..................... 117 Table 6.1: Bulgaria - labor force and activity rates for persons of 15-64 years of age ....................... 123 Table 6.2: Number of employed persons with disabilities in main ALMPs under NAPE .................... 129 Table 6.3: Labor market mediation services for persons with disabilities ......................................... 131 Table 6.4: Costs of measures for persons with disabilities implemented by NEA (in Euro) ............... 133 Table 6.5: Investment support programs for labor market inclusion of persons with disabilities based on PDA and implemented by the Agency for Persons with Disabilities ............................................. 136 Table A.1: Persons with Disabilities in Bulgaria 2017-2019 ................................................................ 165 Table A.2: Persons with disability by age group 2017-2019 ............................................................... 165 Table A.3: Severity of disability by age groups (2019) ........................................................................ 165 Table A.4: Share of persons with disability by severity of disability (2017-2019) .............................. 166 Table A.5: Disability assessment - applications and certifications (2016-2019) ................................. 166 Table A.6: Annual number of persons having received expert decision on permanent disability for the respective year by age groups (2005-2019) ................................................................................. 166 Table A.7: Annual number of persons, having received expert decision (1st time and consecutive) on permanent disability for the respective year by age group and gender ............................................ 166 Table A.8: Persons with (re)issued expert decision during the year by severity of disability and gender (2019 and 2010) ...................................................................................................................... 167 Table A.9: Children with (re)issued expert decision during the year by severity of disability and gender (2019 and 2010) ...................................................................................................................... 167 Table A.10: Persons with (re)issued expert decision during the year by age groups and severity (2019) .................................................................................................................................................. 167 Table A.11: Persons over 16 years old with (re)issued expert decision during the respective year by severity of disability (2005 – 2019) ..................................................................................................... 167 Table A.12: Persons older than 16 years with (re)issued expert decision (for permanent and long- term disability) during the respective year by duration of the certificate (2015-2019)..................... 168 Table A.13: Persons over 16 years old with (re)issued expert decision during the year by duration of the certificate and by severity (2010; 2019) ....................................................................................... 168 Table A.14: Persons over 16 years of age having received expert decision for permanent disability for the first time by main groups of diseases (2010; 2019) ..................................................................... 168 Table A.15: Persons over 16 years of age having received expert decision for the first time (incl. <50% severity) by main groups of diseases (2010- 2019) ............................................................................ 169 Table A.16: Persons over 16 years of age having received expert decision for the first time by main groups of diseases and by severity (2019) .......................................................................................... 170 Table A.17: Children up to 16 years of age having received expert decision for the first time by main groups of diseases and severity (2019)............................................................................................... 170 Table A.18: Persons having received expert decision for the first time (incl. below 50% severity) by age groups (2005-2019) ...................................................................................................................... 171 Table A.19: Persons having received 1-st time expert decision by age groups and severity (2019). . 171 Table A.20: Disability appeals and revoked decisions (2017-2020).................................................... 171 Table A.21: Checks on signals and complaints, and planned inspections (2015-2020)...................... 172 Table A.22: Data on the number of applicants and approved applications for individual needs assessment by the type of benefit requested .................................................................................... 172 Table A.23: Disability pension recipients by type of pension (2012-2019) ........................................ 172 Table A.24: Annual expenditures for disability pensions by type of pension, in thousand BGN (2012- 2019) ................................................................................................................................................... 174 Table A.25: Recipients of disability pension by severity of disability and gender (2019)................... 175 Table A.26: People receiving disability pensions per severity of disability and employment (2019) 175 Table A.27: Poverty line and average pensions in Bulgaria in 2019 (per month) ............................... 175 Table A. 28: Annual newly granted and terminated disability pensions (2010-2019) ....................... 176 Table A.29: Recipients of benefits who have undergone individual needs assessment in 2019 ....... 176 Table A.30: Persons with disability receiving disability related benefit (2017-2019)......................... 176 Table A.31: Tax relief benefits for disability (2017-2019) .................................................................. 177 Table A.32: Persons with disabilities receiving additional monthly supplement for social integration (2010-2019)......................................................................................................................................... 177 Table A.33: Number of persons with disabilities receiving targeted benefits (average number per month) for 2019 .................................................................................................................................. 178 Table A.34: Beneficiaries of assistance by others 2019 ...................................................................... 178 Table A. 35: Targeted benefits for raising children with disabilities (2010-2019) .............................. 178 Table A.40: Self-perceived long-standing limitations in usual activities due to health problem in 2010 and 2019 (population older than 16) .................................................................................................. 179 Table A.41: Share of population over 16 years of age at risk of poverty or social exclusion (2010 and 2019) ................................................................................................................................................... 179 ACRONYMS 2FA Two-factor authentication ALMP Active labor market programs APD Agency for people with disabilities ASA The integrated information system of the Social Assistance Agency CELC Central Medical Expert Commission COM Council of Ministers CPD Commission for Protection against Discrimination CSA Civil Servant Act DCM Decisions of Council of Ministers DTS Disability type and severity EPA Employment Promotion Act ESF European Social Fund EUSILC European Union Survey on Income and Living Conditions GDP Gross domestic product World Health Organization’s International Classification of Functioning, Disability ICF and Health IIS Integrated information system INA Individual needs assessment IPDA Integration of Persons with Disabilities Act ISCME Information System for Control of Medical Expertise ISME Information System “Medical Expertise” LC Labor Code LFS Labor Force Survey LTD Long-term disability MAC Medical Advisory Commission MDS World Health Organization’s Model Disability Survey MLSP Ministry of Labour and Social Policy of Bulgaria MOH Ministry of Health MPAP MATRA Pre-Accession Program NAPE National Action Plan for Employment NCPD National Council on Persons with Disabilities under the Council of Ministers NCPHA National Center for Public Health and Analyses NEA National Employment Agency NEET Neither in employment, nor in education nor in training NFAMA National Framework Agreement for Medical Activities NHIF National Health Insurance Fund NMEC National Medical Experts Commission NRA National Revenue Agency NSI National Statistics Institute OME Ordinance on Medical Expertise OP HRD Operational Program “Human Resources Development” PAA Personal Assistance Act PDA Persons with Disabilities Act PDA Implementation of Persons with Disabilities Act Regulation RAC Real Application Cluster RFME Regional Files for Medical Expertise RHI Regional Health Inspectorates Rules on the structure and organization of work of the bodies of the medical RSO expertise and of the regional filing cabinets of the medical expertise SAA Social Assistance Agency SAD Social Assistance Directorate SPA Social Protection Act SSA Social Services Act SSC Social Security Code SSI Social Security Institute TMEC Territorial Medical Expertise Commission UISME Unified Information System for Medical Expertise UN CRPD United Nation’s Convention on the Rights of Persons with Disabilities World Health Organization’s International Classification of Functioning, Disability WHO’s ICF and Health Acknowledgements This Report was prepared by a team led by Aleksandra Posarac, Lead Economist of the World Banak and co-led by Marijana Jasarevic, Social Protection Specialist of the World Bank. The team included Professor Jerome Bickenbach, Lead Technical Expert, Swiss Paraplegic Society and University of Luzern, and Viktorija Vasiljeva-Gringiene, Yordan Dimitrov, Pavlina Petrova, Pavel Dimov, Miryana Siriyski, Vera Veleva, Ivan Karagyozov and Angel Angelov, World Bank consultants. The Team is grateful for close collaboration and assistance from: Lyubomira Arshinkova, State Expert, Department for Integration of People with Disabilities within the Directorate Disability Policy, Equal Opportunities and Social Assistance at the Ministry of Labor and Social Policy, Marin Baychev, Head of Department for Integration of People with Disabilities Directorate Disability Policy, Equal Opportunities and Social Assistance at the Ministry of Labor and Social Policy, Marc Vothknecht, Head of the Sector for Labor Market and Social Polices, The EC Directorate-General for Structural Reform Support (DG REFORM), Claudia Piferi, Policy Officer, DG REFORM, Oana Dimitrescu, Policy Officer, DG REFORM, Mincho Koralski, Executive Director of the Agency for People with Disabilities of the Ministry of Labor and Social Policy, Sylvia Stoyanova, Operations Officer, World Bank Country Office Bulgaria, Adela Ivanova Delcheva Nachkova, Operations Assistant. The team would also like to thank Cem Mete, Social Protection and Labor Practice Manger and Fabrizio Zarcone, World Bank Country Manager in the Bulgaria Country for the overall support and guidance provided to the team. 1 Executive Summary Introduction This Report was prepared as part of the project “Strengthening Disability System in Bulgaria” (EC reference SRSP2020/49 (20BG06) implemented by the World Bank with funding from, and in collaboration with, the European Commission’s Directorate General for Structural Reform Support - DG REFORM. The specific objective of the project is to support the Ministry of Labour and Social Policy (MLSP) of Bulgaria to strengthen and further develop its disability system, namely through supporting the MLSP in strengthening the individual comprehensive assessment of functioning and needs of persons with disabilities and related administrative processes and supporting MLSP in the development of the institutional and governance structure of the newly proposed State Agency for People with Disabilities. The project expected outcomes are: (i) The State Disability Agency effectively coordinates and monitors disability policy in Bulgaria; and (ii) The Ministry of Labor and Social Policy carries out a well-preforming comprehensive assessment of functioning and needs of persons with disabilities. These outcomes are also in line with the goals of implementation of the government policy on the rights of persons with disabilities. The expected outcomes support the national priorities to guarantee effective social inclusion to people with disabilities. This Report is one of the activities envisaged to contribute to the achievement of the outcome (ii) above. To carry out this activity, the World Bank conducted a mapping and situation analysis of disability system and policy, including disability status assessment and the functioning and needs assessment in Bulgaria. This mapping review is expected to inform the choices of the Bulgarian government regarding strengthening of the individual needs’ assessment process. This activity establishes a base line on the disability system and policy. The review uses as its framework a contemporary understanding of disability as defined by the World Health Organization’s International Classification of Functioning, Disability and Health (WHO’s ICF), as well as the United Nation’s Convention on the Rights of Persons with Disabilities (UN CRPD).1 Based on the the analysis of the current situation, the World Bank team has produced this report summarizing data, analyses, and findings and recommendations. About the terminology: In this Report, we use the terms persons with disabilities and a person with a disability. A key Bulgarian law regulating the rights of persons with disabilities, the Persons with Disabilities Act, understands the persons with disabilities as “persons with permanent physical, mental, intellectual and sensory impairment who may impede their full and effective participation in public life and to whom the medical expertise has established a degree of disability of 50 and over 50 percent”.2 Furthermore, in Article 101, the Bulgarian Health Act stipulates that medical expertise is conducted to establish “temporary work incapacity, type and degree of disability of children up to 16 years of age and of persons who have acquired the right to a social insurance pension based on age and length of work history covered by social insurance contributions according to Article 68 of the Social Insurance Code, and to establish a degree of permanently reduced work capacity of working age adults, as well as to confirm the presence of professional disease.3 Therefore, in this Report, for simplicity and clarity, reflecting the Persons with Disabilities Act, we use the term persons with 1 World Health Organization. 2001. International Classification of Functioning, Disability and Health (ICF). https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and- health. United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) 2006. https://www.un.org/disabilities/documents/convention/convoptprot-e.pdf. 2 Persons with Disabilities Act. Supplementary Provisions Article 1(1). https://www.lex.bg/bg/laws/ldoc/2137189213 (in BG). 3 The Health Act. https://www.lex.bg/laws/ldoc%20/2135489147/. 2 disabilities. For medical expertise and certification of disability, we use the terms, temporary and permanent disability. This Report on the disability system and policy in Bulgaria comprises seven chapters presented after the Overview. Chapter One provides a snapshot of disability statistics using national and EU sources of statistical information. Chapter Two provides a brief review of key legal documents defining disability system and policy and then presents key institutions responsible for disability policy development and implementation. Chapter Three focuses on the disability assessment system in Bulgaria (i.e., in Bulgarian parlance, the system of medical expertise of disability). Chapter Four looks at the individual needs assessment. Chapter Five presents key support measures specifically targeted at persons with disabilities. Chapter Six focuses on the situation and support measures concerning labor market participation of persons with disabilities. Chapter Seven looks at the information systems and data relevant to disability. The main body of the Report is accompanied by five annexes: (i) detailed statistics, (ii) a more comprehensive description of legal framework with (iii) live web links to key pieces of legislation, (iv) detailed description of support measures, including program description, eligibility criteria, administrative processes, and grievance redress arrangements, and (v) templates of documents used for the individual needs assessment. This Executive Summary provides a short summary of findings and recommendations. Conceptual Framework This study follows a contemporary consensual view that disability is a complex phenomenon that involves both biomedical features of a person’s body or mind and the impact of the overall physical social, and environmental context in which the person carries out his or her life. This view, adopted unanimously by the World Health Assembly in 2001 and espoused in the UN Convention on The Rights of Persons with Disabilities stresses that disability is the outcome of an interaction between intrinsic biological features of the person (that is, the person’s state of health) and all aspects of his or her physical, human-built, interpersonal, social, cultural, and political world—the context in which he or she acts, works, and participates in all aspects of personal and social life. This bio-psycho-social model, or interactional view of disability is the dominant one today. Disability is not simply about how a person’s body functions, since two people can have exactly the same problem of bodily functioning—or impairment as it is typically termed—while one experiences a severe disability and the other little or no disability because they live in very different contexts that make very different demands on them: the fact that a person has lost in an accident the first digit of her/his index finger on left hand may mean that she/he cannot do her/his job—because she/he is a concert pianist—or it may not affect her/his employment at all. If a person’s eyesight weakens with age, she or he may have little problem reading or seeing friends across the street because she/he has access to corrective glasses. But someone who has no access to glasses will be severely hampered in his or her day-to-day life, with the precisely same level of limited vision. Clearly, things in the world— the climate, products, buildings, and way cities are laid out, human attitudes and values, and the way the world is organized personally and socially all can make a difference in how individuals experience disability. On the other hand, disability is not just about these environmentally or socially created disadvantages, because the body and how it functions makes a difference as we ll. Indeed, some of the problems humans have in their bodies make all the difference to their experience: If a person has chronic pain, a missing limb, or severe depression; it does not really matter much how her/his community or society at large is organized since this will have little effect on her/his pain level, the fact that she/he does not have a leg or is depressed. Pain and depression medication will help, but medication, though initially part of the person’s ‘environment’ becomes part of her/him when 3 ingested and—either temporarily or permanently—the way her/his body functions change. The body makes a difference in disability, and ignoring the body, or downplaying the importance of the body distorts the concept of disability. The interactional conceptualization of disability is at the heart of the above-mentioned World Health Organization’s International Classification of Functioning, Disability and Health (ICF). The ICF formalizes and operationalizes disability as interactional (based on what is called in the ICF the ‘bio- psycho-social’ model of disability). The ICF arose from a consensus that formed in the late 1990s that an interactional approach was the most defensible way of moving beyond the unhelpful deadlock between Medical and Social models. As an international standard classification, the ICF also moved the debate from the theoretical and political to the scientific and practical levels, transforming the interactional model into a working framework for direct applications in epidemiology, clinical practice, research, and other domains. Although the underlying intuition of the interactional model of disability is generally accepted, the old models, especially the Medical Model, still has a powerful hold over how disability is assessed for policy purposes. This has led to the peculiar situation in which although no one would deny that disability depends both on the state of one’s body and the state of one’s environment, the way disability is assessed in countries around the world suggests that very different conceptions of disability are being presumed. A Snapshot of Disability The prevalence of disability in Bulgaria has been stable, fluctuating between 10 and 11 percent of the population. According to the recent available administrative data (2015-2019), the share of persons with certified permanent disability in the total Bulgarian population has been stable, fluctuating between 10.0 and 11.0 percent.4 In 2019, there were in Bulgaria 753,204 persons formally certified as having permanent disabilities or 10.8 percent of the population. The majority (60.6 percent) were female, with the male share significantly lower at 39.4 percent. This is not surprising, because there is a significant gender difference in life expectancy (at birth in 2020: 69.9 years for males and 77.5 years for females), the male/female sex ratio in the population 65+ years of age of 0.68 and the fact that almost 60.0 percent of persons with disabilities are 65+ years of age. Among persons certified as having a disability, 77.0 percent are certified as having a severe or very severe disability. Malignant neoplasms, diseases of circulatory system, and musculoskeletal diseases are the most common diseases associated with disability. Disability is strongly associated with aging. Disability is much more prevalent among the elderly population. Among persons with disabilities, older adults (65 plus) have the biggest share of 58.3 percent, followed by adults 21-65 years of age – 38.2 percent. Children (up to 18) and younger adults (18-up to 20) - 25,000 persons) made 3.4 percent of all persons with disabilities in 2019. Looking at disability prevalence by the same age groups, the following is observed: (i) among older adults (65 years of age and older), disability prevalence is 29.3 percent; (ii) in the group 20-64 years of age, it is 7.0 percent; and (iii) in the group ap to 20 years of age (children up to 18 and young adults 18-20), it is 2.0 percent. A much higher prevalence of disability among older adults is expected, as it is empirically proven that functional ability decreases with age. This trend will continue with the projected aging of the Bulgarian population. In 2010, the share of older adults (65 plus) in the total Bulgarian population was 17.4 percent, in 2020, 21.3 percent and it is projected to increase to 31.5 percent by 2050, while the 4 For population data, see National Statistical Office of Bulgaria: https://www.nsi.bg/en/content/6727/population-projections-sex-and-age/ 4 overall Bulgarian population is projected to shrink to 5.4 million by mid-21st Century (from 6.9 million in 2020). These trends make inclusion and participation of persons with disabilities crucially important for social and economic prosperity of Bulgaria, calling for strengthening of many policies, including disability assessment and rehabilitation. As with other countries that have been experiencing the aging of the population, Bulgaria needs to start preparing for a future in which a significant fraction of the population will be elderly, many of whom will be experiencing disability. Focusing on prevention, healthy living and aging, and policies to support participation and optimize functioning -- such as remaining active in the labor market -- are key to mitigating the social and economic impact of an aging population increasingly experiencing disability.5 Legal and Institutional Framework Since ratification of UN CRPD in 2012, Bulgaria has made significant efforts to systematically include disability into its legal framework, from the Constitution to various laws to secondary legislation. The basic tenets of disability inclusion have been a respect for and protection of human rights of persons with disabilities, non-discrimination, and specific policies and programs to support persons with disabilities and ensure their inclusion and participation in all aspects of life. One of the recent changes introduced by the Persons with Disabilities Act is the introduction of an individual assessment of needs to which each person with disability has the right. At the same time, a mainstreaming approach – ensuring that persons with disabilities have equal access to mainstream services like everyone else, has been followed too. Efforts have been made to ensure that persons with disabilities are included in all aspects of the public policy development, implementation, and monitoring. In this sense, Bulgaria presents a good practice example of efforts to make national legal framework sensitive to disability and disability rights and inclusion. Reflecting changes in legal provisions, institutional framework for disability system and policies has been adjusted as well. Here too, a dual approach has been followed. Mainstreaming: responsibilities concerning the rights of persons with disabilities and their participation and inclusion have systematically been added to central, regional, and local government bodies and agencies. In addition, several new institutions have been established, such as Monitoring Committee, National Council on Persons with Disabilities, MLSP Directorate for Disability Policy, Equal Opportunities and Social Assistance, Agency for Persons with Disabilities, Coordinators of the Rights of Persons with Disabilities in the central and territorial bodies and Regional Councils. To strengthen coordination of disability policies development, implementation and monitoring, the Persons with Disabilities Act envisages that the Agency for Persons with Disabilities, currently an executive agency under the MLSP Minister, will become a state agency (under the Council of Ministers) as of 2023. Like with all fast-evolving systems, several issues have been observed: • Mainstreaming of disability has played a secondary role: Disability policy has been more focused on introduction of specific support measures to persons with disabilities and specific institutions dealing with persons with disabilities. Mainstreaming has been pursued, as well, but the focus has been on disability specific policies and institutions. While disability specific actions are important, mainstreaming, i.e., ensuring that persons with disabilities are 5 See, for example, WHO. 2015. World Report on Aging and Health. Geneva, 2015. https://www.who.int/ageing/publications/world-report-2015/en/; WHO. 2020. Decade of Healthy Aging. Baseline Report. Geneva, 2020. https://www.who.int/publications/m/item/decade-of-healthy-ageing-baseline- report 5 systematically included in all public policies and institutions and have equal access to them as everyone else is necessary to ensure their full inclusion in society. • Delineation of functions and responsibilities between different institutions is not always clear: Multiple government agencies/bodies are involved in performing similar functions. This is fine if there is no overlap and duplication, as in principle, efficient and effective implementation of programs requires a clear definition of rules, roles and controls and their methodical implementation. It is, hence, advisable to review the functions and performance of all institutions involved in disability policy development, implementation, coordination and monitoring, and the relationship between them, and make sure that the allocation of functions is clear and with no overlap. This is particularly relevant for the transition of the Agency for Persons with Disabilities into a State Agency for Persons with Disabilities. • Policy implementation is operationalized through numerous programs implemented by sectoral ministries through their specialized departments, autonomous agencies and in collaboration with local administration and self-governing bodies. The challenge regarding implementation is to have an appropriate menu of services on the one hand, and sufficient funding and human resources to implement currently available programs and to ensure that persons with disabilities are systematically included in all programs on equal basis as everyone else, on the other. Another important challenge is to ensure cross-departmental collaboration in the programs’ implementation at the local level, i.e., the level where the services are provided to beneficiaries (operational collaboration). • Policy coordination through all phases of public policy making and implementation is one of the most frequently mentioned challenges in public policy. Coordination is a common issue even within the same government entities, let alone in areas such as disability which are cross sectoral and encompass the entire government. Bulgaria has several institutions tasked with coordination of disability policies and programs from national to the local level of government. A review of the work and an assessment of performance of these structures, with a view of strengthening their coordination is recommended. • Policy monitoring needs strengthening: Monitoring is closely related to the reporting hierarchy and accountability for results and is closely linked to the clarity and delineation of functions. Government bodies implementing policy should monitor internally the implementation of programs for which they are responsible to make needed course corrections. The ministries should monitor the work of agencies under their authority; however, they themselves are accountable and should report to the national level bodies for delivering results in their respective policy areas. Finally, the government is accountable to the parliament and ultimately to the citizens. It is therefore important to have clarity concerning who reports to whom, who is accountable to whom and who monitors whom for transparent and effective governance and good results. While there are some elements of monitoring built into the current institutional framework in Bulgaria, overall, disability policy implementation monitoring arrangements, except at the national level, are not entirely clear. Monitoring also seems to be cojoined with implementation, so in one state body one finds policy development, regulation, implementation, and monitoring. This is not a good practice and internal and external monitoring ought to be clearly defined to avoid a conflict of interest. • Difference between conceptual approach to disability and implementation on the ground . As noted, in its legislative framework, Bulgaria has adopted approach to disability espoused by UNCRPD, which understands disability as the outcome of an interaction between a person's health state and the physical, human-built, and social environment that impacts on the person's participation in major life areas and as a human rights issue. Yet, the medical approach to disability strongly permeates the policy implementation on the ground. This is clearly reflected in the medical approach to the assessment of disability, which is key for 6 persons with disabilities to access publicly provided benefits and services and thus cascades into them. Disability status assessment (medical expertise of disability) The current work incapacity and disability status assessment system is purely medical. It is limited by the fact the methodology used in the assessment, a Baremic type instrument that matches diseases and impairments with percentages of disability, does not assess disability, in the modern sense established by the ICF and enshrined in the UN CRPD. A Barème instrument purports to assess disability as if it were the same thing as a medical condition or impairment, ignoring environmental factors that determine the disability that an individual experiences. The associations between disease and impairment, on the one hand, and percentage of disability on the other are not based on empirical evidence but are conjectural. Barème instruments tend to be scientifically weak and allow for manipulation and biased judgment.6 It is now commonly understood throughout Europe and the world that diminished work capacity and disability must be assessed as the lived experience of an individual living with one or more health problems – or in ICF terms, as the level of a person's performance in light of his or her intrinsic health capacity and environmental facilitators or barriers. Disability assessment is a 'whole person' or global assessment of the extent or level of a person's disability. As a result, disability assessment should be a summary measure of functioning levels across domains of actions, simple and complex, from walking, taking care of children to working at a job. A summary or global assessment of disability must be based both on the individual health state and on specific assessments of specific activities as performed in the person's actual environment. Yet a summary assessment of disability is valid only if the specific assessments can be statistically summarized into a single assessment score. Bulgaria, like most countries in Europe, has recognized that the concept of 'disability' needs to be understood as a complex phenomenon that results from the interaction of the health problems and impairments people have and their environment. Features of a person's environment can make disability more severe (climatic conditions, building construction, stigma, and attitudes) or less severe (assistive technology, modifications to home environments, supportive friends and family). This is the model of disability found in the ICF and the CRPD. Moreover, the Bulgarian Persons with Disabilities Act explicitly defined people with disabilities consistent with the ICF approach: people with disabilities " are persons with physical, mental, intellectual and sensory insufficiency, who in interaction with their environment could hinder their full and effective participation in public life." While countries are taking steps to move away from a purely medical assessment of disability of the sort represented by the Medical Expertise, Bulgaria has yet to take the concrete steps needed to do so, consistent with its own legislation. Administratively, the assessment of temporary and permanent disability is organized in Bulgaria differently from many other countries. In Bulgaria, these functions that are important both for affected persons and the state is delegated to medical establishments, engaging several thousands of medical doctors. As evidenced by high numbers of inspections of medical advisory committees responsible for temporary disability assessment (MACs; there are almost 3,000 MACs across the country), and territorial medical expertise commissions, responsible for permanent disability (TMECs; almost 70) and appeals, the system is not fully trusted by the public. While the model does help achieve better territorial coverage of disability certification services, it is difficult to eliminate the 6 Bickenbach J, Posarac A, Cieza A and Kostanjsek N. 2015. Assessing Disability in Working Age Population – A Paradigm Shift: from Impairment and Functional Limitation to the Disability Approach . Report No: ACS14124. Washington, DC.: The World Bank. Council of Europe. 2002. Assessing Disability in Europe – Similarities and Differences. Integration of People with Disabilities. ISBN 92-871-4744-2. Strasbourg. 7 conflict of interest (in small towns where everyone knows everyone) or achieve a strict and consistent application of the medical expertise methodology. Moreover, the current system incurs increased cost due to additional diagnostic procedures requested by assessors (often conducted in the same medical establishment where the TMEC is), thus increasing the cost of the assessment both to the budget entities funding them, as well as to individuals, in case they must pay for them. An applicant’s journey through the system of MACs and TMECs appears long and complex. To an outsider looking at the system from the regulatory documents, it appears that there is an endless demand for medical documents, additional diagnostic procedures, multiple applications, and multiple commissions. The decisions take long time (e.g., TMEC may take three months to issue a decision). The newly established information system for medical expertise, alleviates, but does not eliminate several of these concerns (see section below on disability information management systems and data). We therefore recommend: • Revision of the disability status assessment system for permanent disability by introducing functioning aspects into disability assessment through the application of a valid and reliable, extensively empirically tested psychometric instrument. The change in methodology should be based on empirical evidence (rather than speculation or professional fiat). This evidence can be statistically developed into an automated algorithm that would calculate degrees of disability in a scientifically sound, non-arbitrary or non-discretionary fashion.7 • Create specific disability assessment methodologies that are adapted to specific situations of children, the working age population, and older people (above statutory retirement age). • Bulgaria might wish to reconsider administrative process through which temporary and permanent disability are determined. For disability assessment, it may consider establishing a dedicated agency, with permanent experts and territorial branches. This is how disability assessment and certification are organized throughout the world. Normally, this agency is under the ministry of health, ministry of social affairs or they share authority over the assessment body. Often, work capacity is assessed by a social security agency. A single agency ensures consistency in assessment practice, assessors’ capacity development, monitoring of decisions and, if organized well, with check and balances, transparency, and predictability in the application of the assessment and decision-making procedures. On the other hand, among issues raised concerning a single assessment body are geographical access to the assessment branch and the opportunities for bribes and rent seeking. The former can easily be resolved through good planning of assessment schedule and having mobile assessment teams. The corruption issue is not easy to resolve under any system, but there are ways to organize the assessment to minimize opportunities for rent seeking/bribing. Potentially, Bulgaria can transform the National Medical Expert Commission into an executive agency with territorial divisions covering the whole country. For the sick leave, the Ministry of Health and the National Social Security Institute should jointly reconsider the current organizational model and redesign the administrative process and entities involved in it, moving towards one that uses 7 Test piloting of the WHO’s functioning assessment instrument – Disability Assessment Schedule 2.0 (WHODAS 2.0) conducted within the same project under which this Report was prepared, provides an opportunity for Bulgaria to consider systematic inclusion of functioning into disability status assessment based on empirical evidence. The WHODAS 2.0, 36-question version was pilot-tested in Bulgaria on about 3,200 applicants for disability assessment in late 2021-early 2022. The statistical analysis of the pilot data confirmed that WHODAS is psychometrically valid and reliable instrument that captures the ICF construct of disability and that including it into disability assessment in Bulgaria would significantly improve the accuracy of disability determination. For more information see: Carolina Fellinghauer, Aleksandra Posarac, Jerome Bickenbach and Marijana Jasarevic. 2022. Options for Improving Comprehensive Functioning and Needs Assessment in Bulgaria @World Bank. 8 information technology and electronic exchange of documents/information to decide on the sick leave extensions. • Ministry of Health, National Medical Expert Commission, National Social Security Institute, and other key stakeholders should come together and map all administrative processes by types of assessment with the objective of making the client journey through the system transparent, easier, shorter and less time consuming. • Referrals to MACs and TMECs should all be electronic through the regional health files/ISCME only. • Implement a one-stop shop approach across the board. The flow of documents should be electronic and automated, and applicants should not be asked to provide medical or other documentation unless the documents are missing. Even in such situations, the documents should be obtained by institutions through official exchange of information (this should not be complicated in an integrated information system). • All assessments should include a face-to-face interview, as an essential part of collecting information for disability assessment. • Introduce a rule that a patient seeking MAC or TMEC decision should be assessed only by a MAC or TMEC operated by a different medical institution from the one where she/he was treated. The referrals to a concrete MAC, TMEC or NMEC should be done by the regional health files/ISCME to ensure the application of this principle. Ideally, RHF would also schedule appointments with MACs or TMECs. Individual needs assessment The introduction of the individual needs assessment of persons with disabilities is a very important step in the implementation of the United Nations' Convention on the Rights of Persons with Disabilities. In 2019, the Person with Disabilities Act introduced a complex individual needs assessment in Bulgaria. This is a very important step in the implementation of the United Nations' Convention on the Rights of Persons with Disabilities that mandates that persons with disabilities have the right to the provision of health and social services "based on the multidisciplinary assessment of individual needs and strengths". In the context of health and social welfare programming for persons with disabilities, the individual needs assessment is a tool that identifies what a person requires in terms of supports and services in response to needs that are created by problems in functioning that result from an underlying health problem – disease, injury or other condition that results in one or more impairments of body functions or structures. As implemented in practice, the individual needs assessment is yet to be consistent with the modern concept of disability. Article 20 of PDA created the legal right of persons with disabilities to a complex and individual assessment of needs that examines "the functional difficulties of a person with a disability, related to her/his health condition and the presence of barriers in the performance of daily and other activities, as well as the type of support needed." This statement reflects the concepts of functioning and disability found in the World Health Organization's International Classification of Functioning, Disability and Health (ICF), and as well the CRPD's characterization of 'persons with disabilities'. There is, however, no further mention of the ICF in either PDA or its PDA Regulation. The link between the individual needs assessment and the ICF is most clearly made in Article 1 of the Methodology for Conducting an Individual Assessment of the Needs for Support to Persons with Disabilities. However, the characterization of the 'bio-psycho-social model” is somewhat confused. For although disability is described as a problem in functioning (or 'functionality' as it is termed), functionality itself is characterized as a capacity of the body not, as in ICF, the outcome of an interaction between the capacity of the body and environmental factors. Moreover, unlike the ICF, 9 the environment – called 'possibilities' – is described as preventing "the person with a disability from fulfilling its functionality through relevant actions," rather than, as in the ICF, creating the level of functionality in the person's performance of activities. As these differences are fundamental, it is hard to say that the current individual needs assessment described in the needs assessment methodology is consistent with the ICF. Currently individual needs assessment plays a limited role. Within the current context of medical certification of disability and eligibility rules for support measures to persons with disabilities, individual needs assessment plays a limited role. Decisions on the needs for important support measures, such as personal assistance or the need for technical aids are de facto made by the medical certification commissions as part of the disability certification. Thus, individual needs assessment serves as an instrument to determine the level (hours) of personal assistance and as eligibility screening tool for measures administered by the Social Assistance Agency or a referral tool for measures implemented by other government bodies (where, such as the case of social services, additional needs assessment may be conducted). Medical approach to disability permeates. As noted, the certification of disability in Bulgaria is made based on medical criteria. In addition, the social worker form of the needs assessment tool introduces the notion of “functional insufficiency” (intellectual, physical, psychological, sensory and “other illnesses”) in a “yes”/”no” answer format, which pertains to an impairment/medical diagnosis. Information on functioning is collected only in the case when a person requests personal assistance. Thus, it is difficult to understand how the needs are determined without first assessing problems in functioning experienced by a person with a disability in her/his home, community, and work environment. The tools used for the individual needs assessment reflect the context and overall heavy focus on disability as a medical issue. Looking at the tools, the following is observed: The Social Worker Form 1) Part 2: Medical Expertise Findings and Part 3 Information on the functional insufficiency/health condition of the person with disability are unnecessary as the full NMEC/TMEC/MAC report should already be available. In addition, Part 3 introduces a completely different concept ('functional insufficiency') that serves no function in the assessment. 2) Part 4: Information on the existing problems with the functioning of the person with disabilities and Part 5: Information on the impact of constraints on the life of the person with disability are only used to determine whether personal assistance is required but is far more detailed than is required for that purpose. In addition, 'total scores' are calculated merely by adding up the scores for each question, but the result is meaningless since the scores for each question are not comparable and cannot be added together. Moreover, the initial score is augmented by coefficients, but it is not clear why and which methodology was used to determine them. This total score is then brought forward in 7.3 Need for personal assistance. 3) Part 6: Participation in education or in the labor market only asks the open-ended question 'What kind of support is the person with disability applying for?' but gives no indication of whether that support is needed or on what basis that decision is made. 4) Part 7: People surrounding the person with disability and need for social services/personal assistance, Part 8: Targeted aid, and Part 9: Provision of monthly financial support merely record the social worker decisions about several kinds of supports (personal assistance, housing, auxiliary aids and medical devices, financial support for motor vehicle, balneological treatment and/or rehabilitation services, monthly financial support) without any indication of how that decision is made or on what basis. 10 5) Part 10: Wishes of the person with disability and additional information merely repeats information already collected or asks about the persons motivation for social integration. Again, there is no indication how this information is used. In summary, overall, the social worker’s form either collects information already collected or records the social worker's decision about a specific need without indicating what evidence was used or what the basis for the decision was. The scoring mechanism is technically questionable as it is not legitimate to simply add up scores from different domains as they are not commensurable. The Self-assessment Form The Self-assessment Form is a long list of questions, including a series of questions in seven domains of functioning with answers in a “yes”/”no” format. Several questions pertain to demographic information that should already be available from TMEC/NMEC and civil registry. The “yes”/”no” format severely limits the value of information that is collected through this questionnaire. Field conversations with social workers indicate that many persons with disabilities find it difficult to fill in the questionnaire. Moreover, the self-assessment plays a limited role in the assessment. Administrative process to apply for the individual needs assessment is demanding. The applicants are required to submit documents most of which should be available in the Civil Registry, Information System for Control of Medical Expertise/Regional Files of Medical Expertise Medical Files, Social Security Institute, National Employment Agency, Tax Administration, etc., and an applicant should not be asked to provide them, save for an application, identity document and a self-assessment form. Even an application submission could be eliminated and each person who has gotten a certificate from TMEC/NMEC (or a referral from MAC) could automatically be referred to a social assistance local department for a needs assessment. A referral could also include (agreed) documents in electronic format.. A person with a disability could be then invited to submit a self-assessment and indicate which service she/he would wish to receive. Ideally, parts of the needs assessment templates should be populated automatically, including personal information, TMEC/NMEC certificate information, information on current benefits received by a person (SSI, SAA), etc. Considering that the needs assessment is new, and that the implementation thus far could be considered as trial and learning period, based on the above observations, we recommend: • Revise the needs assessment tools to collect information on problems in functioning, identify the needs whose fulfillment within the existing services and support measures can improve functioning (or experience of persons with disabilities in their everyday life) and, considering wishes of persons with disabilities, determine eligibility or link (refer) them to the support measures and institutions that provide them. Save for the TMEC/NMEC decision, eliminate medical information from the needs assessment tools. • Apply a full needs assessment to all persons with disabilities. • Consider having TMEC/NMEC/MACs recommending, not deciding on, support measures and make decisions only after a full functioning and needs assessment has been completed. • Simplify the administrative process by introducing an automatic referral from TMEC/NMAC to individual needs assessment, minimizing documents requirements from an applicant and using extensive information systems already in operation to automatically pull out personal and other information and documents. • Continuously train staff in the functioning and needs assessment. • Establish a technical and methodological individual needs assessment unit in SAA (or the Disability Policy Directorate of MLSP) that would conduct econometric and statistical analysis 11 of the INA data and monitor the trends. Establish a team of rehabilitation specialists in the Social Assistance Agency to guide social workers conducting individual needs assessment. • Move towards introducing a multidisciplinary needs assessment where the SAA would continue to be responsible for it, as it is now, and social workers would play a role of true case managers, but the assessment teams would include other relevant sectors and experts (teachers, pedagogues, psychologists, medical doctors, rehabilitation experts, etc. as needed by each case). Measures to support persons with disabilities Bulgaria features an impressive list of publicly financed social protection and other programs to support persons with disabilities.8 Benefits range from cash transfers to technical aids, care services, to residential placement, as well as benefits such as tax reduction, free/subsidized transportation, discounted admission into museums, etc. Support is provided both by the state and municipalities. Support to persons with disabilities is regulated by various laws and associated regulations of the Council of Ministers and other relevant government bodies. Very important changes to the disability benefits system were introduced recently with the Persons with Disabilities Act, Social Services Act, Personal Assistance Act, and others. Particularly important were the introduction of a comprehensive individual needs assessment and a personal assistance program, which compensates (mostly) family members for taking care of persons with disabilities in the form of formal employment. Different programs require different degree of disability, with some available only to persons with a degree of disability >90.0 percent. For several benefits, such as services of an assistant or a disability pension supplement for assistance by others the TMECS’ decision that a person should be assisted by others is needed as well. The coverage by disability support interventions seems high. While data on support measures included in this chapter may not be complete, based on information presented, there were in 2019 about 1.7 million benefit “units” provided to persons with disabilities or about 2.3 per person with disabilities, including children. In 2019, among the 753,204 persons with disabilities, 513,180 were receiving a disability pension, 73,637 received a supplement to a disability pension for assistance by others, 654,960 received monthly financial assistance, 237,392 used free annual road toll vignette and all children with disabilities were covered by monthly financial allowance. While no data is available on distribution of support measures and whether and how many persons with disabilities do not receive any support, available data suggest complete coverage by at least one support measure. The level of various cash benefits varies significantly indicating insufficient synchronization across the system. Given that persons with disabilities can and do receive several cash benefits, it is impotent to ensure consistency in setting their level and ensure their synchronization to avoid adverse incentives and allow them to achieve their objectives. Some monetary benefits are rather low. Tracking who receives what is important, first and foremost for the well-being of persons with disabilities, but also for the efficiency and effectiveness of the system. A database of persons with disabilities, currently with the Agency for Persons with Disabilities provides an excellent tool for collation of such information. Public expenditure on disability support measures is significant. Public expenditure, as available data show is at about 1.4 percent of GDP in 2019 (higher than 1.2 percent reported by Eurostat, which may be due to different methodology). The expenditure data is not complete, as the cost to the budget of the health insurance coverage, reduced/no co-pay for health services, social care services, 8 Health, including medical rehabilitation and education services are not included in this report. Labor market interventions to support employment of persons with disabilities are discussed in Chapter 6. 12 employment support measures, the medical rehabilitation, municipal benefits, forgone budget revenues due to income tax base reduction, etc., is not included. Development of social services for persons with disability has lagged. In the structure of support measures to persons with disabilities, monetary measures dominate. Social services are underdeveloped in Bulgaria, with uneven geographical coverage. Low numbers of users suggest limited supply and menu of services. While Bulgaria has undertaken lots of efforts to deinstitutionalize care, residential care institutions still play an important role. Community based care services, and early intervention and preventive services are in their infancy. The menu of services is limited. There are municipalities in the country where there are no social services, as well as municipalities where there is only one type of social service provided. Only few municipalities, mostly in large urban centers, provide a wider range of social services. Some groups of persons with disabilities are especially disadvantaged – persons with psychiatric disorders, persons with severe intellectual disabilities and people with dementia. The new Social Services Act sets out an ambitious agenda for the development of social services, but it needs time, resources and persistence before significant results will have been achieved. In any case, given a critical importance of social services for improving functioning of persons with disabilities, the development of these services ought to be a priority for authorities in Bulgaria. Administrative process to acquire benefits seem complicated and time-consuming. A review of programs to support persons with disabilities shows that persons with disabilities are required to apply for each disability benefit separately (a demand-based approach), even in cases when several benefits are administered by one agency. This supposes that they know which benefits are available and how to access them (for technical aids and rehab services people are asked to find providers as well, which is mostly not the case. While each implementing agency is mandated to provide pertinent information on its website, there is no integrated information available in one place and no single entry through the government portal to access it. Often, persons with disabilities are asked to submit same documents repeatedly, despite the existence of several management information systems that are supposed to contain a comprehensive information on each person with disabilities and can formally exchange them. Furthermore, currently, there is a complex, individual needs assessment, “preliminary” needs assessment and needs assessment (by social services providers). This is probably the consequence of a fast-changing system, where legal provisions change frequently, while administrative processes take time to adjust. In the view of the above, we recommend: • Provide information on programs available to persons with disabilities. Information on different benefits is available on respective websites of government agencies administering them. But an information source with comprehensive, integrated information is not available. To that end, a booklet with all programs, including their eligibility requirement and how and where to apply for them should be available in regularly updated electronic and printed formats. The printed booklet should be handed to each person applying to MAC/TMEC/NMEC. Ideally, this information should be compiled and maintained by the government body responsible for the coordination of disability policy as it requires inputs from various agencies at the national, regional, and local levels of government. • Integrated management information system. An integrated management information system is needed to enable automatic information flow between various relevant agencies: from the health system, including MACs to TMECs/NMEC; from TMECs/NMEC to SSI and SAA; from SAA to government departments implementing various programs (as a referral together with the needs assessment and an action plan), etc. In this way, the process will be much less onerous to persons with disabilities, information flow smooth and decision making easier. There should be no need for persons with disabilities to submit the same documents repeatedly – most of 13 them are already stored in the information system of the regional health files and should be available to officers in other relevant agencies while performing their official duties and following data privacy protection rules. • Make administrative processes for acquiring disability benefits smoother, better integrated and less demanding: The linkages between disability certification (TMEC/NMEC), a complex, individual needs assessment (SAA), an action plan development (should be done by local offices of SAA in a multidisciplinary fashion), referrals (by SAA) and access to services (persons with disabilities, service providers) ought to be much better integrated. In that, the PDA individual needs assessment should play a critical role, including in matching and linking individuals and benefits/services available to them. • Improve information on each person with disability. The database on persons with disabilities, currently maintained by the Agency for People with Disabilities of MLSP, which contains extensive information on everyone with disability in Bulgaria, should be able to also collate information on benefits they receive. The data should be available to program administrators in carrying out their official duties, to policy makers, and, in anonymized format, to universities and academia for research. • Prioritize development of community based social care services for persons with disabilities. Social care services development has lagged, although they are critical for optimizing functioning of persons with disabilities to ensure their full inclusion and active participation in life. Labor market inclusion of persons with disabilities Low level of labor market participation, i.e., very high level of labor market inactivity is one of the key features of labor market participation of working age persons with disabilities in Bulgaria . According to the Bulgaria Labor Force Survey (LFS) 2019, of all estimated working age persons with disabilities, 24.0 were active in the labor market (either as employed or unemployed) and 76.0 percent were inactive. Of those active, 92.6 percent were employed and 7.4 percent unemployed. Of all working age persons with disabilities, 22.0 percent were employed. If one combines data on employment of persons with disabilities from LFS and data on persons with disabilities formally registered as unemployed from the National Employment Agency (NEA), then the labor force participation rate increases to 27.2 percent and the unemployment rate to 19.3 percent. (This is not methodologically entirely correct, but it may suggest higher unemployment rate among persons with disabilities than what the LFS estimates.) Labor market indicators for persons with disabilities are not different from what one observes in other EU countries. Available and relatively comparable data from other EU countries show a similar picture of low labor force participation of persons with disabilities. Some, such as Latvia, Lithuania, France, and Germany feature higher unemployment rates of persons with disabilities than Bulgaria.9 Factors driving low supply of labor among persons with disabilities are not understood well; understanding them would allow for better tailored policies to maximize their labor force participation. There are two sets of key issues here. One pertains to understanding why most of the working age adults certified as having a disability leave employment upon being certified and rarely, if ever, return to the labor market. In Bulgaria, most of them are in their mid-fifties or older, with lower education level and are certified as having reduced work capacity of 50 percent of more due to cancer, musculoskeletal or cardiovascular diseases. The second set pertains to working age adults who have been disabled since childhood. While some barriers to employment faced by either group are similar, there are very significant differences too. Adults in the labor market who have been disabled since 9 See Chapter 6 for discussion and observations and recommendations. 14 childhood tend to have low or no education/skills, they often need higher level of support/accommodation, they face strong societal prejudice, etc. Working age adults who have acquired disability during their adulthood have often completed lower secondary education or higher, most have families, and most are in employment at the time of acquiring disability. For this group, the challenge is to ensure their continued employment, should they wish so, as many may find the opportunity cost of continued employment too high relative to their health concerns and changed life priorities. The labor market policies are focused on unemployed persons with disabilities. There are very few efforts to support continuous employment of persons on a long sick leave, or those referred to TMECs/NMEC for disability certification. Occupational and vocational rehabilitation are underdeveloped, and workplace accommodation is rare. Providing support for a continued employment of persons on extended sick leave or undergoing certification is potentially a game changer in efforts to increase labor force participation of persons with disabilities – the objective in this case is encourage and support such persons not to leave employment after they have been assessed as disabled. The menu of labor market services is focused on subsidies to employers. NEA does not provide or support services such as coaching to employees and employers, specific workability assessment, work processes and working condition assessment and adaptation, case managers and other staff trained and experienced in working specifically with persons with disabilities, etc. Most programs are aimed at employers through wage subsidies. The integrated (multidisciplinary) approach to service provision is undeveloped . The PDA calls for the integration of occupational, vocational, medical, social, and psychological rehabilitation, but this is yet to be put into practice. Projects implemented under OP HRD provide good lessons in the provision of multidisciplinary labor market services to persons with disabilities. The services are not sufficiently tailored to different needs of different groups of persons with disabilities. The current ALMPs do not make difference between different types of disability, functioning limitations, congenital and acquired disabilities, experienced and inactive people. Such specialization and diversification are pursued in many EU countries (Belgium, France, Netherlands, etc.). Interventions’ tailoring is crucial, as encouraging and supporting continued employment needs a different mix of services than support for entering labor market for young people with disabilities or returning to the labor market for those who have been inactive. Private employers are still skeptical about working with persons with disabilities, particularly persons with intellectual disabilities since childhood. The introduction of quotas for persons with disabilities in 2019 did not turn into (somewhat unrealistically) expected engine for expanding employment among persons with disabilities. Many employers met their quotas by reporting their employees with disabilities; some chose to pay the fine rather than hire an additional employee, or they just did not manage to find suitable candidates as the supply of labor among persons with disabilities is small. Another reason is that employers are worried about the fact that they cannot easily dismiss a person with a disability due to additional legislative protection. Monitoring and evaluation need strengthening. Although NEA conducted an impact evaluation several years ago and APD commissioned a survey on labor market participation of persons with disabilities in 2019 (the data is not publicly available), there is a need to continuously monitor performance of policy and interventions to support labor market inclusion of persons with disabilities. This is needed for policy corrections and further development. Available statistical information suggests modest impact and high cost of implemented interventions. 15 We thus recommend: • Conduct a study on determinants of labor force participation of persons with disabilities, with the following cohorts in focus: first time entrants with disabilities into the labor market (young adults with disabilities), adults with disabilities since childhood and adults with disabilities who are employed but may leave the employment due to disability. • Develop and deploy labor market policies specifically targeting adults with disabilities at risk of leaving the labor market because of disability. The objective is to encourage/support their continuous employment in the same job with the same employer, different job with the same employer or a new job with a new employer (should they wish to remain employed). Here, a multidisciplinary approach with collaborative effort including a person herself/himself, NEA, health and social services and assistance authorities at the local level, and employers is needed. • Establish in NEA a specialized unit for labor market inclusion of persons with disabilities with case management approach for groups requiring longer term, complex interventions. to support services are needed to address the specificities of persons with disabilities at the labor market. Consolidate labor market interventions in support of employment of persons with disabilities under NEA. • Tailor programs to specific needs of different groups of persons with disabilities and increase the menu of services, including vocational and occupational rehabilitation. Foster multidisciplinary, integrated approach in assessing the needs, developing a plan of support, and implementing it. • Systematically monitor and evaluate programs for evidence-based policy development. Plenty of data is already collected. The APD’s Register on Persons with Disabilities contains a wealth of data on labor market activities of each person with disabilities. SAA also collects data through the individual needs assessment. These data need to be available for analysis and policy making (in anonymized format). Information systems and data Bulgaria has several information systems relevant for disability system and policies, including: (i) the information system for medical expertise that automates all processes related to it; (ii) the information system of the Agency for Social Assistance that automates all of its business processes, including the individual needs assessment; and (iii) the information system for persons with disabilities housed by the Agency for Persons with Disabilities that collates all information on persons with disabilities to create a comprehensive profile of each person with a disability; (iv) information systems of the Health Insurance Fund and the Ministry of Health; (v) information system of the Social Security Institute; (vi) civil registry information system; etc. For the purpose of this report, we have looked at the first three. Important processes concerning disability system and policies are automated, including certification of disability, individual needs assessment, application for, processing and delivery of many social assistance benefits, etc. There is a significant exchange of information between various information systems, making the client journey and work of officials easier and creating a possibility for strong reporting and monitoring of policy implementation. The system(s) are built in such way that manual data entry is allowed as well, which is pertinent to persons who lack access to internet or are not proficient in the use of web-based applications. 16 Yet, some important processes are not automated, such as those related to sick leave. More importantly, different disability system and policy relevant information systems are yet to be fully integrated. By integration, we mean that people should not be repeatedly asked to submit copies of various documents (TMEC decision, medical documents, etc.) – these should be available in the information system. Personal information from the civil registry should be automatically retrieved and populated into relevant blanks when persons interact with the system. The referrals to benefits and services should be automatic too. For example, once a person has been issued a TMEC decision, she/he should be automatically referred to SAA for a needs assessment with all relevant documents. Similarly, all MAC documents should follow the person when the person is referred for a medical expertise. The persons in question should be able to see her/his electronic file and flag incorrect or missing information, but she/he should not be asked to provide copies of documents. Finally, the potential of the Register of Persons with Disabilities comprising their comprehensive individual profiles is yet to be realized to provide much needed, up-to-date data for evidence-based disability policies. Despite the existence of this Register, data on disability in Bulgaria is not easy to find and one must search different sources and institutions to compile even a basic set of data needed for a simple description of the disability system and policies, let alone a more sophisticated statistical analysis. But the data exist in the Register, and if presented in an anonymized format it would be a treasure trove of data for research and studies and evidence-based policy making. It only needs to be made available to the public at least through: (i) a standardized set of tables that should be posted on the APD/MLSP website; (ii) analytical reports based on the data, and (iii) an anonymized data base made available for analyses to academia, researchers, and policy makers. We thus recommend: • A fast completion and deployment of the information system for sick leave, which should be tightly integrated with other relevant information systems (Regional Health Files, ISME, SAA, SII, NHIF, etc.). • A tighter system integration and automatic exchange of real-time information on persons with disabilities including MACs, TMECs/NMECs, Regional Health Files, Ministry of Internal Affairs, Ministry of Regional Development and Public Works, SSI, NHIF, SAA, etc. • Introduction of two-factor authentication (2FA) for identification in the system. • Introduction of electronic signature for all documents. • Establish a set of tables from the Register of Persons with Disabilities to be regularly published on the website of MLSP/APD, prepare and publish an analytical report based on data and made the micro data in an anonymized format available to academia, researchers, and policy makers. Such evidence-based reports are crucial to monitor the policy implementation and for evidence-based policy making. 17 Chapter 1: Disability at a Glance In this chapter, we look at statistical information pertaining to disability in Bulgaria. Mostly, we look at disability prevalence and trends. We use the most recent data available, disaggregated by age, gender, severity of disability and main health conditions. Detailed statistical information is provided in Annex 1 to this Report. 1.1. Disability prevalence and trends To look at disability prevalence and trends in Bulgaria, we use the following currently available sources of data: administrative data from the Agency for People with Disabilities (APD; data availability starts from 2015/2017 onwards), the Ministry of Health (MOH), the National Center for Public Health and Analyses (NCPHA), the National Social Security Institute (NSSI), the National Revenue Agency (NRA), and the Social Assistance Agency (SAA). Administrative data on persons with disabilities concern individuals of all ages who have been certified by the medical expertise system as persons with disabilities; and (ii) the Eurostat data from the European Union Survey on Income and Living Conditions (EUSILC).10 EU SILC presents data collected through a population survey in which individuals 16 years of age or older self-report “long-standing limitations in usual activities due to health problems”. Disability is a complex, evolving and multi-dimensional phenomenon and population surveys and other sources of data may use various definitions, interpretations, and approaches to try to measure it. While the temptation is great to directly compare Bulgaria’s disability rates based on administrative and EU SILC data, it is not advisable to do so, as these data sets are not directly comparable. They capture and measure different aspects of disability and any comparisons would require an in-depth analysis with plenty of caveats. Administrative data Disability prevalence: According to the recent available administrative data (2015-2019), the share of persons with certified permanent disability11 in the total Bulgarian population has been stable, fluctuating between 10.0 and 11.0 percent (Figure 1.1).12 In 2019, there were in Bulgaria 753,204 persons formally certified as having permanent disabilities or 10.8 percent of the population. The majority (60.6 percent) were female, with the male’s share significantly lower at 39.4 percent. This is not surprising, because there is a significant gender difference in life expectancy (at birth in 2020: 69.9 years for males and 77.5 years for females), the male/female sex ratio in the population 65+ years of age of 0.68 and the fact that almost 60.0 percent of persons with disabilities are 65+ years of age. Making international comparisons of disability prevalence is hard, as one would need to compare what can be compared, in this case, the prevalence of persons formally certified as having a disability. Such data is not easily available, except in country-specific studies. The only data we could find was on Latvia (10.0 percent disability prevalence) and Lithuania (8.2 percent) - both for 2018, and 10 EU SILC data sets are available on the Eurostat web site – data and database: https://ec.europa.eu/eurostat/data/database 11 In this Report, unless otherwise stated, when we talk about persons with disabilities in Bulgaria, we refer to persons formally certified by relevant government authority as having permanent disability. 12 For population data, see National Statistical Office of Bulgaria: https://www.nsi.bg/en/content/6727/population-projections-sex-and-age/ 18 Azerbaijan (6.2 percent in 2019).13 Relative to these three countries, Bulgaria records the highest disability prevalence. A low disability prevalence in Azerbaijan is likely mostly driven by its young population (median age of 32.6 years, compared to Bulgaria’s 43.7, Lithuania’s 44.5 and Latvia’s 44.4), although other factors such as disability assessment criteria and their application, and socio-economic determinants of health play a role as well. For example, in Azerbaijan, elderly population above working age is not formally certified for disability. Therefore, even when one compares seemingly comparable data, one should be careful when drawing conclusions and must make sure that all caveats related to data comparability are considered. Figure 1.1: Stable trend: persons with permanent, formally certified disability in Bulgaria 2015-2019 Source: Agency for People with Disabilities (APD) Persons with disabilities by age: Among persons with disabilities, older adults (65 plus) have the biggest share of 58.3 percent, followed by adults 21-65 years of age – 38.2 percent. Children (up to 18) and younger adults (18- 20 years of age - 25,000 persons) made 3.4 percent of all persons with disabilities in 2019 (Figure 1.2). Figure 1.2: Most persons with disabilities are over 65 years of age - Persons with disabilities by age groups 2017-2019 Source: APD 13 See, Posarac, A., Bickenbach, J., and Celmina, E. (2020). Disability Policy and Disability Assessment System in Latvia © World Bank; and Posarac, A. (2020). Disability Policy and Disability Assessment System in Lithuania © World Bank. For Azerbaijan, see the Ministry of Labor and Social Protection of the Population of Azerbaijan website. 19 Looking at disability prevalence by the same age groups, the following is observed: (i) among older adults (65 years of age and older), disability prevalence is 29.3 percent; (ii) in the group 20-64 years of age, it is 7.0 percent; and (iii) in the group up to 20 years of age (children up to 18 and young adults 18-20), it is 2.0 percent (Figure 1.3). Figure 1.3: Disability prevalence by age groups in 2019 (the prevalence calculated as the share of persons formally certified as having a disability >50 percent relative to the total population in that group) Children and Overall prevalence young adults 10.8 Adults Elderly Source: Based on APD data and UN population data for Bulgaria. A much higher prevalence of disability among older adults is expected, as it is empirically proven that functional ability decreases with age. This trend will continue with the projected aging of the Bulgarian population. In 2010, the share of older adults (65 plus) in the total Bulgarian population was 17.4 percent, in 2020, 21.3 percent, and it is projected to increase to 31.5 percent by 2050, while the overall Bulgarian population is projected to shrink to 5.4 million by mid-21st Century (from 6.9 million in 2020). These trends make inclusion and participation of persons with disabilities crucially important for social and economic prosperity of Bulgaria, calling for strengthening of many policies, including disability assessment and rehabilitation (discussed in subsequent chapters of this Report). Persons with disabilities by severity and age group: The severity of permanent formally certified disability can be grouped into four categories based on the final percentage of reduced work capacity/disability, as determined by Territorial Medical Expert Commissions (TMEC) or the National Medical Expert Commission (NMEC) – see subsequent chapters: low/no disability (below 50.0 percent), moderate severity (between 50.0 and 70.0 percent disability), severe disability (between 70.0 and 90.0 percent) and very severe disability (over 90.0 percent).14 The severity per age groups confirms that most severe cases of disability are in the group of older adults (over 65), almost 30.0 percent (Figure 1.4). In 2019, the youth entering adulthood (18 to 20 years of age) also reported higher percentage of very severe disability (25.7 percent) compared to children (22.0 percent) and adults (21.0 percent). 14 The terminology used “moderate”, “severe” and “very severe” is not an official classification, it marks only the disability ranges that give specific rights. 20 Figure 1.4: Severity of disability increases with age - Disability by age and severity in 2019 Source: APD Figure 1.5 presents changes in the composition of all persons with disabilities by severity. There is a significant change in this indicator in 2019, when the share of persons with moderate permanent disability was 33 percent, compared to 16 and 17 percent in 2018 and 2017, respectively; the share of persons with very severe disability was 25 percent, compared to previous years of over 40 percent. The share of persons with severe disability stayed relatively stable. This change is due to the change in the disability assessment methodology pertaining to how co-morbidity is counted in determining the percentage of disability (see footnote).15 Figure 1.5: Severe and very severe disability dominate - Persons with disability by severity of disability 2017-2019 Source: APD 15 The change in the composition of persons with disabilities by age and severity was a discrete event. The Disability Assessment Methodology (Annex II of the Ordinance on Medical Expertise – OME) was changed in mid-2018 in a way that co-morbidities ceased to be considered in determining the percentage of disability, thus lowering it. Previously, the disability percentage determined based on the primary health condition/impairment was augmented by adding percentages related to co-morbidities with weights ranging from 5 to 20 percent, at the discretion of the assessor. This was subject to numerous complaints spurring the revisions. The methodology now augments the primary percentage of disability by adding 20 percent for a comorbidity but ONLY if this comorbidity severity alone is assessed at over 50 percent. 21 Irrespective of the change in the methodology, over two thirds of persons with disabilities are certified as having severe (70-90 percent) or very severe (over 90 percent) disability (43 and 25 percent, respectively). This is almost 7 percent of the population. Every year more than 2.0 percent of the population applies to undergo medical expertise for certification and recertification of disability (in 2019, 2.3 percent of the population) – Table 1.1. Table 1.1: Applications for and completed medical expertise cases 2016 -2019 (permanent disability) 2016 2017 2018 2019 Applications for the first-time medical expertise and a repeat medical 167,605 172,650 163,390 163,670 expertise Medical expertise completed and 162,220* 156,758* 151,113* 159,551 certificate on % issued Of which for the first time applicants 52,264 48,388 48,292 49,587 Source: MH Annual Reports; National Center for Public Health and Analyses (NCPHA) *Excluding children. As can be seen from Table 1.1, the medical expertise service completes most of the applications (97.5 percent in 2019). Of all completed expertise cases, 31.0 percent were for the first-time assessment. The number of completed cases does not equal the number of persons assessed as disabled, because some were assigned <50.0 percent disability, which would not qualify them for any benefits. (To qualify for benefits a person should be certified as having a degree of disability of at least 50.0 percent). Figures 1.6 and 1.7 present numbers of persons by age groups (16 and over) who have received an expert decision on permanent disability 2010-2019, respectively in absolute numbers and percentages of the total. Figure 1.6: Persons 16 and over who have received expert decision on permanent disability 2010-2019, by age groups 200,000 180,000 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 2010 2015 2016 2017 2018 2019 16-19 20-39 40-59 60+ Total Source: National Center for Public Health and Analyses (NCPHA) 22 The Figure 1.6 shows that between 2010 and 2019 the total number of (re)certified persons decreased by about 6.0 percent. Among different groups, the most notable increase was in the 60 plus years of age group, while the most notable decrease in absolute terms was in the 40-59 years of age group. The composition by age groups (Figure1.7) mirrors the changes in absolute numbers: the share of 60 plus increased by 31.0 percent, while the share of 40-59-year-old persons decreased by 14.0 percent. Figure 1.7: Percentage shares of persons 16 and over who received expert decision on permanent disability 2010-2019, by age groups 57.0 52.0 52.7 51.9 50.8 49.5 39.4 37.9 36.6 36.2 35.5 31.3 11.3 10.2 10.2 10.1 9.8 9.6 0.5 1.1 1.6 1.7 1.7 1.4 2010 2015 2016 2017 2018 2019 16-19 20-39 40-59 60+ Source: National Center for Public Health and Analyses (NCPHA) Figures 1.8 and 1.9 present persons (16 and over) who received an expert decision on permanent disability in 2010 and 2019 by the assigned percentage of disability. The following is observed: the share of those assigned a percentage of less than 50 increased from 7 to 11 percent. Yet, 89.0 percent of those assessed are assigned a percentage of at least 50, qualifying them for various disability- related benefits. One contributing factor is likely a high share of older adults among persons with disability – almost 60.0 percent. Other contributing factors are yet to be investigated. 23 Figure 1.8: Persons 16 and over who received expert decisi on on permanent disability by the assigned degree (in %) of disability in 2010 2010 7% 21% Very severe (>90%) Severe (70-90%) 37% Moderate (50-70%) Low/no (<50%) 35% Source: National Center for Public Health and Analyses (NCPHA) Figure 1.9: Persons 16 and over who received expert decision on permanent disability by the assigned degree (%) of disability in 2019 2019 11% 21% Very severe (>90%) Severe (70-90%) Moderate (50-70%) 39% 29% Low/no (<50%) Source: National Center for Public Health and Analyses (NCPHA) Figures 1.10 and 1.11 present data on leading causes for permanent disability in Bulgarian population among persons who were formally certified for the first time as having a disability (16 years of age and over). The diseases of the circulatory system record the highest share, followed by neoplasms and diseases of the musculoskeletal system and connective tissues (Figure 1.10). Looking at the severity of disability by disease groups, the highest share of cases with very severe permanent disability is in 24 the group of infectious and parasitic diseases (over 70 percent) and in neoplasms (over 55 percent) – Figure 1.11. Figure 1.10: Persons 16 and over having received expert decision for permanent disability for the first time by m ain groups of diseases in 2010 and 2019) Source: NCPHA Figure 1.11: Persons 16 and over who received expert decision for permanent disability for the first time by main groups of diseases and severity of disability in 2019 Source: NCPHA 25 European Union Survey on Income and Living Conditions (EUSILC)16 Another source of data on disability prevalence in Bulgaria is the EU SILC. In this European wide survey, disability is defined as “long-standing limitations in usual activities due to health problems”. The data are self-reported. Table 1.2 Presents data for 2019. In the EU-27, 24.0 percent of the population aged 16 and over reported (some or severe) long-standing limitations in their usual activities due to health problems (hereafter referred to as long-standing limitations): 17.2 percent reported some long-standing limitations and 6.9 percent reported severe long-standing limitations. Across the EU Member States, the share of people who reported some or severe long-standing limitations ranged from 11.8 percent in Malta, 13.1 percent in Sweden and 16.1 percent in Bulgaria to 35.0 percent in Estonia, 35.7 percent in Finland and the highest in Latvia 39.5 percent. The highest shares of people reporting severe long-standing limitations were registered in Austria, France, Belgium, Slovakia, Greece and Croatia, all 9.0 percent or higher, with the highest share in Estonia (11.5). Bulgaria, as shown, reported 12.9 percent of some long-standing limitations, and 3.2 percent of severe. None long standing limitation was reported by 83.9 percent of the population. Overall, in the EU, Bulgaria is among the countries with the lowest share of the population reporting long-standing limitations (Figure 1.12) and this has been consistent since the inception of EU SILC in Bulgaria. Table 1.2: Distribution of persons by self -reported long-standing limitations in usual activities due to health problems, by sex, 2019 (% share of the population aged 16 and over) Total Males Females Total Males Females Some None Some None Some None Severe Severe Severe EU-27 17.2 6.9 76.0 15.7 6.1 78.2 18.6 7.5 73.9 EA-19 17.1 6.9 76.0 15.7 6.2 78.1 18.3 7.6 74.1 Belgium 17.9 9.2 72.8 17.0 8.3 74.7 18.8 10.1 71.1 Bulgaria 12.9 3.2 83.9 10.9 3.0 86.1 14.8 3.3 81.8 Czechia 20.8 7.7 71.4 18.7 7.2 74.1 22.3 8.1 69.5 Denmark 25.3 5.8 68.9 23.9 5.1 71.0 26.7 6.4 66.9 Germany 14.7 7.1 78.2 14.4 6.8 78.8 15.0 7.5 77.5 Estonia 23.5 11.5 65.0 22.1 10.0 67.9 24.7 12.8 62.5 Ireland 11.2 5.1 83.6 11.1 4.9 84.0 11.4 5.4 83.3 Greece 13.6 9.5 76.9 12.2 8.8 79.0 14.9 10.1 75.0 Spain 14.7 3.8 81.6 13.3 3.1 83.7 16.0 4.4 79.6 France 15.8 9.2 75.0 14.4 8.6 77.0 17.1 9.7 73.2 Croatia 23.7 10.6 65.6 22.4 9.7 67.9 24.9 11.5 63.6 Italy 16.7 5.4 77.9 15.1 4.5 80.4 18.2 6.3 75.5 Cyprus 16.7 6.8 76.5 16.4 6.4 77.2 16.9 7.2 75.9 Latvia 30.9 8.6 60.5 27.5 7.3 65.1 33.5 9.6 56.9 16 EU SILC data sets are available on the Eurostat web site – data and database: https://ec.europa.eu/eurostat/data/database 26 Lithuania 25.2 6.5 68.3 22.0 5.6 72.5 27.8 7.3 64.9 Luxembourg 17.9 7.6 74.5 16.5 6.8 76.7 19.2 8.5 72.3 Hungary 17.7 7.1 75.2 15.7 6.4 77.9 19.5 7.6 72.9 Malta 9.2 2.6 88.2 8.1 2.4 89.6 10.4 2.8 86.8 Netherlands 24.3 5.0 70.7 22.0 3.7 74.3 26.5 6.3 67.2 Austria 24.9 9.0 66.1 24.3 8.4 67.3 25.5 9.6 64.9 Poland 16.8 7.6 75.6 15.4 7.4 77.3 17.9 7.8 74.2 Portugal 25.1 7.9 67.0 20.9 6.5 72.6 28.8 9.2 62.1 Romania 19.4 6.0 74.6 16.5 4.3 79.2 22.1 7.7 70.2 Slovenia 19.6 8.8 71.5 17.6 8.5 73.8 21.6 9.1 69.3 Slovakia 22.2 9.2 68.6 20.0 7.9 72.0 24.2 10.4 65.0 Finland 28.1 7.6 64.3 24.1 7.8 68.1 32.2 7.3 60.5 Sweden 9.0 4.1 86.9 7.0 3.6 89.4 11.1 4.6 84.4 United 15.8 11.5 72.7 14.4 10.6 75.0 17.0 12.5 70.5 Kingdom* Iceland 13.5 12.5 74.0 10.9 9.3 79.8 16.3 15.7 68.0 Norway 12.5 5.7 81.8 9.6 4.6 85.8 15.4 6.9 77.7 Switzerland* 24.7 5.5 69.8 22.6 4.9 72.5 26.8 6.1 67.1 North 8.9 5.8 85.3 7.0 4.9 88.1 10.7 6.8 82.5 Macedonia Serbia 9.7 4.5 85.8 8.2 3.6 88.2 11.1 5.4 83.6 Turkey 17.6 8.1 74.3 14.3 6.9 78.8 20.8 9.3 69.9 * 2018 data. Source: Eurostat (online data code: hith_silc_12) Figure 1.12: Persons self-reporting long-standing limitations in usual activities due to health problems, by country and by severity (% share of the population aged 16 and over) 40 35 30 25 20 15 10 5 0 France Finland Denmark Latvia Hungary Romania Norway Serbia Turkey Belglum (2) Germany Greece Spain Cyprus Austria Croatia Iceland (3) Poland EA-19 Bulgaria Ireland Italy Malta Netherlands Slovenia Slovakia Luxembourg Portugal Czechia Estonia Lithuania United Kingdom (3) EU-27 (1) Sweden Switzerland North Macedonia Some Severe Figure 1.13 presents data on long-standing limitation from EU SILC for EU-27 and Bulgaria over 2014- 2019. In both, all indicators have declined in the observed period. As noted, Bulgaria’s indicators are well below those in EU-27. 27 Figure 1. 13: Persons 16 years of age and over self -reporting long standing limitations in usual activities due to health problems in Bulgaria and EU -27 2014-2019 30 25 20 15 10 5 0 EU-27: % persons BUG: % persons EU-27: % persons BUG: % persons EU-27: % persons BUG: % persons with long- with long- with long- with long- with long- with long- standing standing standing standing standing standing limitations limitations limitations - SOMElimitations - SOME limitations - limitations - SEVERE SEVERE 2014 2015 2016 2017 2018 2019 Source: Eurostat (hlth_silc_12) EU SILC data for EU-27 show that: (i) women are more likely to report long standing limitations than men, (ii) the prevalence and severity of reported limitations increases with age and is inversely corelated with income and education (those with higher income and higher level of education self- report lower prevalence of long-standing limitations.17 Bulgaria follows the suite. While, as we have explained above, a direct comparison between administrative data and EU SILC data is not feasible or advisable, putting them side by side may provide some “food for thought” for policymakers in Bulgaria (Figure 1.14). Figure 1.14: EU SILC and administrative data on disability in Bulgaria, 2019 Disability prevalence in Bulgaria, Persons with long-standing limitations in administrative data (2019) Bulgaria – EU SILC (2019) Overall: 10.8% Overall: 16.7% Some/moderate (50-70%): 2.7% Some: 12.9% Severe (70-90%): 4.6% Very severe (>90%): 3.5% Severe: 3.2% Severe & very severe: 8.1% Figure one suggests the following observations. More people self-report experiencing long-standing limitations, relative to the percentage of people certified as disabled. But the difference is much smaller than in many other EU countries (see Table 1.2). The difference is expected as EU SILC collects self-reported information – in other words, the respondents express their subjective perception about limitations. Another difference is that in EU SILC data, a vast majority - 76.0 percent of the survey participants - report experiencing “some” limitations. In contracts, among persons certified as having a disability/limited work capacity, this share is only 25 percent. In EU SILC, 3.2 percent self-report 17 See: Eurostat, Functional and Activity Limitations Statistics. https://ec.europa.eu/eurostat/statistics- explained/index.php?title=Functional_and_activity_limitations_statistics#Home_care_services/ 28 experiencing severe limitations, while administrative data report 8.1 percent, suggesting that medical criteria used in medical expertise may be biased towards higher levels of disability/decreased work capacity. While not directly comparable, the differences are very large and call for empirical research to better understand them and inform disability policy, including disability assessment criteria. 1.2. Key messages Stable disability prevalence trend. According to administrative data from the National Center for Public Health and Analyses and Agency for Persons with Disabilities, Bulgaria’s prevalence rate of disability (persons of all ages formally certified as having a disability) was 10.8 percent of the population in 2019 (753,204 persons). The rate has been stable over the last decade, fluctuating between 10 and 11 percent. Among them, 77.0 percent are certified as having a severe or very severe disability. While not directly comparable, EU SILC data estimate that in 2019, 16.1 percent of the population 16 and over years of age self-reported experiencing long standing limitations in usual activities due to health problems – a decrease of 2 percentage points since 2014; 83.9 percent self-reported not experiencing any difficulties. Among those who self-reported difficulties, 20.0 percent (or 3.2 percent of the total) self-reported experiencing severe limitations. Disability prevalence varies significantly by age cohorts. Among persons with disabilities, older adults (65 plus) have the biggest share of 58.3 percent, followed by adults 21-65 years of age – 38.2 percent. Children (up to 18) and younger adults (18-20 years) made 3.4 percent of all persons with disabilities in 2019. These numbers translate into the following disability prevalence rates: 2.0 percent among children and young adults (up to 20 years of age); 7.0 percent among adults 20-65 years of age and 29.3 percent among older adults (65 years and older). High disability prevalence among older adults and their high share in the overall disability prevalence is not unexpected as it is empirically observed that disability prevalence increases with age, and Bulgaria’s population is aging. Between 2010 and 2019 the share of elderly population (older than 65) increased from 17.4 to 21.3 percent, or by 22.0 percent. The share of 65+ is projected to increase to 31.5 percent by 2050, while the overall population in Bulgaria is projected to decline to 5.4 million. One would, thus, expect that disability prevalence would be growing in the decades to come. Among persons formally certified as having a disability/decreased work capacity, women constitute a majority (60.6 percent). This is not surprising, because there is a significant gender difference in life expectancy (at birth in 2020: 69.9 years for males and 77.5 years for females), the male/female sex ratio in the population 65+ years of age of 0.68 and the fact that almost 60.0 percent of persons with disabilities are 65+ years of age. As with other countries that have been experiencing aging of the population, Bulgaria needs to start preparing for the future in which a significant fraction of the population will be elderly, many of whom will be experiencing disability. Focusing on prevention, healthy living and aging, and policies to support participation and optimize functioning -- such as remaining active in the labor market -- are key to mitigating the social and economic impact of an aging population increasingly experiencing disability.18 18 See, for example, WHO. 2015. World Report on Aging and Health. Geneva, 2015. https://www.who.int/ageing/publications/world-report-2015/en/; WHO. 2020. Decade of Healthy Aging. 29 Chapter 2: Disability policy and system: legal and institutional framework In this chapter we provide a brief overview of the legal provisions and institutional framework for disability system and policy in Bulgaria. The purpose of this chapter is not to analyze or compare Bulgaria to other countries, but to describe the current legal and institutional framework for disability policies and programs. See annexes 2 and 3 to this Report that respectively provide details about key legislative acts and their list with live web links. Also, in the subsequent chapters of this Report we refer to relevant legislation as needed. 2.1. Summary of key legal provisions Regarding disability, the Bulgarian legal framework key objective is to support integration of persons with disabilities in all areas of life, provide guarantees for their equality and support them in exercising their rights. Disability system and policy in Bulgaria is regulated by many laws, starting with the Constitution, and by a large body of regulatory acts issued by various government bodies and agencies responsible for the development of disability related policies and their implementation. Among the key laws building the foundation on which persons with disabilities can exercise and enjoy their rights in Bulgaria are the Constitution of Republic of Bulgaria, the Persons with Disabilities Act, the Anti- Discrimination Act, the Social Services Act, the Social Security Code, the Labor Code, the Employment Promotion Act, the Child Protection Act, the Health Act, the Health Insurance Act and the Personal Assistance Act, and associated secondary regulation. Looking at various legal acts and secondary regulation, it is obvious that Bulgaria’s legislators, policy makers and society have made tremendous efforts to systematically include the rights of persons with disabilities in all relevant laws and regulations. In that sense, Bulgaria can serve as a good practice example. Below, we briefly present key legislative acts as they pertain to disability. 2.1.1 The Constitution The Constitution19 sets the founding principles on which the whole legal paradigm related to policy on disabilities is built. The Constitution also establishes a bridge between the Bulgarian legal framework and the United Nations Convention on the Rights of Persons with disabilities (UNCRPD)20 requirements to protect and respect human honor and dignity, and to prevent any discrimination: “All human beings are born free and equal in dignity and rights” (Article 6, Paragraph 1). “No privileges or restriction of rights are allowed on the grounds of race, national or social origin, ethnic self-identity, sex, religion, education, opinion, political affiliation, personal or social status or property status” (Article 6, Paragraph 2). The Constitution also stipulates that persons with physical or mental disabilities and old people who have no relatives and cannot support themselves are subject to special protection of the state and the society. 2.1.2. Persons with Disabilities Act The Persons with Disabilities Act21 stipulates and guarantees benefits and rights of persons with disabilities and establishes the structure of the main bodies responsible for coordinating and implementing the state disability policies. It defines persons with disabilities, persons with permanent Baseline report. Geneva, 2020. https://www.who.int/publications/m/item/decade-of-healthy-ageing-baseline- report 19 The Constitution of the Republic of Bulgaria. In force since July 13, 1991 (with subsequent amendments). https://lex.bg/laws/ldoc/521957377 20 Ratified by an Act of the Parliament, SG No. 12/2012). 21 The Persons with Disabilities Act. In force since January 1, 2019. https://www.lex.bg/bg/laws/ldoc/2137189213 30 disabilities, individual needs, persons with difficulties in movement, disability prevention, etc. It regulates many aspects and areas of importance for inclusion and participation of persons with disabilities. It defines areas of support for persons with disabilities, including healthcare, education, employment, housing, accessible environment in urban areas and public buildings, transport, culture, sports, personal life, public and political life, and justice (Article 5, Paragraph 1). Support measures to ensure social inclusion of persons with disabilities include: medical, professional, social, occupational and psychological rehabilitation, education and vocational training, services supporting access to employment, accessibility and reasonable accommodation, social services, financial support, accessible information, access to justice and legal protection, ensuring personal mobility with a maximum degree of independence, personal assistance, and universal design (Article 5, Paragraph 2). The Act guarantees to persons with disabilities the right to independent decision-making. It also guarantees access to persons with permanent disabilities to employment in a regular work environment, etc. To tailor support to the needs of individuals with disabilities, the Act introduces individual approach in supporting persons with disabilities based on a comprehensive assessment of individual needs (Article 20; this assessment is discussed in Chapter 4 of this Report). It stipulates that each person with disabilities has a right to an assessment of her/his individual needs. This assessment examines functional difficulties a person with a health condition/ disability is experiencing in her/his everyday life in their own environment: barriers and facilitators in the performance of daily and other activities, as well as the type of support they need to optimize their functioning. The Act also stipulates that the Agency for Persons with Disabilities should be transformed into a State Agency for Persons with Disabilities, which inter alia should coordinate disability policies at the national level. 2.1.3 Anti-Discrimination Act The Anti-Discrimination Act22 provides the legal framework for combating discrimination and for promoting equality. The Act (Article 4) considers as discrimination harassment based on sex, race, nationality, ethnicity, human genome, citizenship, origin, religion or faith, education, beliefs, political affiliation, personal or social status, disability, age, sexual orientation, marital status, property status, as well as sexual harassment, provocation of discrimination, persecution and racial segregation. Public places and environment inaccessible to persons with disabilities are also perceived as discriminatory. The Act regulates procedures for protection against discrimination and how to implement them. 2.1.4. Social Services Act The Social Services Act23 regulates provision, use, planning, financing, quality, control, and monitoring of social services in Bulgaria. The approach underlying this Act is harmonization of provisions in other regulation and creating a coherent link between this Act, the Persons with Disabilities Act, and the Personal Assistance Act. The Act guarantees equal access to social services, meeting individual needs of beneficiaries, the right of every person to support for living in a home environment and in the community, promoting an integrated approach in providing support to individuals and promotion and development of the public-private partnership in the provision of social services. The Act expressly prohibits any form of discrimination. Based on the age of users, social services may be for children and for adults, including children and adults with disabilities and persons taking care of them. Social services can be used without a formal 22 The Anti-Discrimination Act. In force since January 1, 2004. https://www.lex.bg/laws/ldoc/2135472223 23 The Social Services Act. https://www.lex.bg/bg/laws/ldoc/2137191914 31 referral. The Act underlines the rights of persons with disabilities to social services as regulated by the Persons with Disabilities Act; to use these services without a preliminary assessment of needs or a referral from the relevant authority. The Act defines conditions for placing children into residential care. Residential care for children up to three years of age is not allowed, except for children with permanent disabilities who need constant medical care and supervision, which cannot otherwise be provided. Parents of children with permanent disabilities, families and persons taking care at home of adults and elderly persons with permanent disabilities not able to care for themselves have the right to a substitute care. The Act also introduces services of an assistant to persons above the working age who are not able to care for themselves. The Act espouses a holistic, integrated approach to service provision, which is of particular importance for persons with disabilities, because they often need complex actions, services, and supports. This approach includes coordination and interaction with other government bodies, as well as within the system of social services. The Act regulates actions to prevent the abandonment of a child with a disability. The Act introduces new quality standards and methods for their verification. It also regulates in detail social services providers and their licensing. 2.1.5. Child Protection Act The Child Protection Act24 regulates child protection, including special care for children with disabilities. The Act defines child protection as a system of legislative, administrative, and other measures for guaranteeing the rights of every child. The Act stipulates that a special care for children with disabilities should be provided to protect their rights. The Social Assistance Directorate should provide special care for children with disabilities through multilevel actions, including consultations with a medical doctor, psychologist, pedagogue, or other specialists, if necessary, depending on the type and severity of disability. 2.1.6 Health Act The Health Act25 guarantees equality in using health services, provision of quality and affordable healthcare, health promotion and integrated disease prevention, and prevention and reduction of risk to public health from the adverse impact of factors in the environment. Persons with disabilities have the right to health care as all health insured persons, regardless of the type and degree of their disability. They can be treated in hospitals, which are contractual partners of the National Health Insurance Fund, in all clinical pathways, clinical procedures, highly specialized medical treatment, be provided medical devices when needed, according to the same principles on which the hospital treatment of other patients is based. Through the provisions in the Act, the state provides special health protection for people with physical disabilities and mental disorders. The Act stipulates that the quality of medical care should be based on medical standards. Regarding medical rehabilitation of persons with disabilities, the healthcare standard is guaranteed through mandatory application of the clinical pathways. The Act also sets out a framework for disability certification in Bulgaria. It stipulates that medical diagnosis is essential for medical expertise of work capacity/disability. Medical expertise is performed for establishing: (i) a temporary incapacity for work, (ii) a type and degree of disability in children up to 16 years of age and in adults who have acquired the right to a social insurance old age pension; (iii) a degree of permanently reduced work capacity in persons in working age; (iv) an occupational disease. The Act defines permanently reduced work capacity as a situation in which due to a chronic disease(s) and accident(s) at work a person has reduced work capacity. The type and degree of 24 The Child Protection Act. https://www.lex.bg/laws/ldoc/2134925825 25 The Health Act. https://www.lex.bg/laws/ldoc/2135489147 32 disability is defined as a condition of chronic illness or injury due to which a person experiences permanent functional deficit of a relevant impaired organ or system. The medical examination is organized and managed by the Ministry of Health and by the Regional Health Inspectorates. The type and degree of disability and the degree of permanently reduced work capacity is determined in percentages. The Act establishes Territorial Medical Experts Commissions (TMECs) and a National Medical Experts Commission (NMEC) to carry out medical expertise. NMEC coordinates the development and implementation of policies pertaining to medical expertise. TMECs perform the expertise of the type and degree of disability, the degree of permanently reduced work capacity and occupational diseases, the need for technical aids, etc. (TMECs and NMEC are discussed in the next chapter.). The NMEC is responsible for the development of an information data base of all persons who have passed through TMEC/NMEC (Information System for the Control of Medical Expertise, see next chapter). The database should contain (for each person): an application-declaration for disability/ reduced work capacity certification/re-certification; a referral to medical expertise (medical protocol /medical direction); experts’ decision; a diagnosis of the primary disease; diagnoses of the co - morbidities; all performed medical-diagnostic activities related to the assessment; examinations performed by a doctor related to the assessment; other data of importance for the assessment of the degree of disability/permanently reduced work capacity. 2.1.7 Personal Assistance Act The Personal Assistance Act26 regulates the terms and conditions for the provision and use of personal assistance. The Act defines personal assistance as a support mechanism to persons with disabilities for full participation in society, to carry out activities corresponding to personal, social, and domestic individual needs, and to overcome the barriers to their functioning limitations. The persons who can benefit from the services of a personal assistant, include: (i) a child with type and degree of disability that is 90 or over 90 percent or a degree of permanently reduced work capacity without specified assistance by another person ; (ii) a person with an established type and degree of permanent disability or permanently reduced work capacity with specified assistance by other people; (iii) a user of social services in the community, with the exception of social or integrated health-social services for resident care; (iv) a foreigner with a disability who has a long-term or permanent residence permit in the Republic of Bulgaria, etc. A personal assistance user may be a child with a permanent disability for whom a monthly allowance is received, or a person who receives a supplement for assistance by others to her/his disability pension. To access this benefit, an applicant must undergo an assessment of her/his individual needs. The provider of personal assistance is a municipality at the present address of a user. The mayor of the municipality can contract a social services provider holding a license for provision of the social service for assistance support that meet the Act’s requirements. An assistant is a natural person chosen by the user of personal assistance, a person authorized by her/him or her/his legal representative to provide personal assistance through a contract signed by the relevant parties. 2.1.8. Employment Promotion Act The Employment Promotion Act27 regulates provision of programs to facilitate labor market inclusion of the unemployed, including promotion of employment, labor market mediation services, vocational training and guidance including to persons with disabilities. The Act defines disadvantaged groups in 26 The Personal Assistance Act. https://www.lex.bg/bg/laws/ldoc/2137189250 27 The Employment Promotion Act. https://lex.bg/laws/ldoc/-12262909 33 the labor market as groups of unemployed persons with lower competitiveness in the labor market, including unemployed youth, unemployed youth with permanent disabilities, unemployed youth in/ graduates from residential care, long-term unemployed, unemployed people with permanent disabilities/reduced work capacity, and unemployed single parents (adoptive parents) and/or mothers (adoptive mothers) with children under 5 years of age. The Act envisages wage subsidies to employers employing persons with disabilities. Annually, the National Action Plan for Employment28 includes projects, programs, and measures for the employment of unemployed persons, including unemployed persons with disabilities. For instance: For every job that employs an unemployed person up to the age of 29 with permanent disabilities/reduced work capacity, including persons with military service related disabilities, as well as young people using social or integrated health and social services for residential care who have completed their education and are referred by a branch of the Employment Agency, the employer is provided a wage subsidy for up to 18 months. For each job created and filled on a full- or a part-time basis by permanently disabled unemployed persons, including persons with military service related disabilities, who have been hired upon referral from the divisions of the Employment Agency, the employer is paid a subsidy for the period of employment of such persons but not for longer than 12 months, etc. An unemployed person with disability registered with the Employment Agency may apply for supported employment benefit as well when she/he meets legal requirements. They can participate without restrictions in the intermediation services supporting placement in the primary labor market, and in all programs, projects and measures for training and employment, implemented by the Employment Agency, if they meet the requirements. 2.1.9. Labor Code The Labor Code29 prohibits discrimination based on mental or physical disability, provides various forms of protection for persons with disabilities: e.g., mothers who take care of children with disabilities regardless of their age, except with their written consent, are prohibited to work night shifts or overtime; employees with permanently reduced work capacity of 50 percent and above are entitled to basic paid annual leave of not less than 26 working days; an employee with permanently reduced work capacity of more than 50 percent, who is employed fixed term and whose salary in the new job is lower than the salary in the previous job, is entitled to financial compensation for the difference in salary according to a separate law; protection in the case of dismissal; determines quota for employees with disabilities, and a percentage of jobs for vocational rehabilitation. 2.1.10. Civil Servant Act The Civil Servant Act30 provides various forms of protection for persons with disabilities in public administration (free access for persons with disabilities to the buildings in which the administration 28 National Action Plans for Employment, which have been the main financial instrument for funding active labor market programs from 2013: https://www.mlsp.government.bg/natsionalni-planove-za-deystvie-po-zaetostta 29 The Labor Code. https://www.lex.bg/laws/ldoc/1594373121 30 The Civil Servant Act. https://lex.bg/laws/ldoc/2134673408 34 carries out its activities, adaptation of workplace, paid leave), as well as determines quotas for persons with disabilities to be employed in public sector. 2.1.11. Social Security Code The Social Security Code31 guarantees pensions and other benefits to insured persons. It provides that the time during which the care is provided to a person in need of a third person’s assistance is counted as covered by insurance upon retirement. It can be credited to one of the following persons: husband (wife), parent (adoptive parent) or one of the parents of the mother or father of the person with disabilities, on condition that during that time the caregiver was not insured and did not receive a personal pension. Upon retirement, for the period that is considered as the insured length of service, social security contributions are paid to the Pension Fund by the state budget on the minimum wage in effect on the date of granting the pension. The National Social Security Institute provides compensation in cases of temporary partial disability (sick leave) and vocational rehabilitation and pensions in case of permanent disability, according to the Social Security Code. 2.1.11. Health Insurance Act The Health Insurance Act32 guarantees equality in the use of medical care for all insured persons, including persons with disabilities. Under this Act the state budget covers the insurance of veterans and war victims who do not have other health insurance, persons with disabilities, and victims of natural disasters and accidents. The state budget covers the insurance - unless covered otherwise - of persons who receive a disability pension, as well as parents, adoptive parents, spouses or one of the parents who takes care of a child or a person with disability over 90 percent in need of assistance by others. Insured persons suffering from chronic diseases who need continuous medical supervision, supportive care or specific care are exempt from fees for visiting their general practitioners, dentists, or hospital admission. The list of diseases is part of the National Framework Agreement between the National Health Insurance Fund (NHIF) and the Bulgarian Medical Association, the Bulgarian Dentists' Association, and the Bulgarian Pharmacists' Union, which regulates the type and scope of medical services paid by the NHIF. All war disabled and persons with a determined disability of over 71 percent are also exempt from the user fees for the NHIF-reimbursable health services. 2.2 Institutional structure for disability system and policy Here, we present an overview of key government bodies involved in disability policy development, implementation, monitoring and coordination in Bulgaria. A detailed description of the institutional framework pertaining to disability system and policies in Bulgaria is provided in the Report prepared by the World Bank where the institutional framework for disability system and policies is compared with those in France, Slovenia, and the Czech Republic.33 31 The Social Security Code. https://www.lex.bg/laws/ldoc/1597824512 32 The Health Insurance Act. https://www.lex.bg/laws/ldoc/2134412800 33 A. Posarac et all. 2021. Strengthening Disability System in Bulgaria: Review of EU Relevant Practices Regarding Creation and Functioning of Disability Agencies. © World Bank. 35 2.2.1 The framework’s general structure The main law that establishes a structure of bodies responsible for coordinating and implementing state disability policy in Bulgaria is The Persons with Disabilities Act.34 According to this Act, the powers to implement disability policies are distributed between the central (national) and local government levels (Figure 2.1). At the central (national) level: • The Council of Ministers of the Republic of Bulgaria determines the government policy on the rights of persons with disabilities. • The National Council on Persons with Disabilities is an advisory body, established under the Council of Ministers for the purpose of cooperation in developing and pursuing the policy on the rights of persons with disabilities. In this way a cooperation is established between state, municipal, public, and economic entities and institutions, organizations, and non- governmental organizations of persons with disabilities. Figure 2.1: Main bodies responsible for the development, regulation, implementation, coordination, and monitoring of disability polic y in Bulgaria Council of Ministers National Council on Persons with Ministry of Labor and Monitoring Committee Disabilities under the Council of Ministers Social Policy Disability Policy, Equal Opportunities and Social Assistance Policy Commission Ombudsman Organizations of and Directorate for of the for persons with Protection Republic of disabilities and Against Bulgaria Bulgarian Academy Discriminatio of Science n Representative Employment Social Agency for Agency for s of workers, Agency Assistance the Quality of Persons with employees, Agency Social Disabilities employers’ Services organizations Territorial National Divisions: Association of Regional Regional Municipalities Directorates for Councils Social Assistance in the Regional Administrative Regional and Centers and Municipal Directorates Administration “Social Assistance” Coordinators Source: Prepared by the World Bank team. • The Ministry of Labor and Social Policy, supported by the Directorate for Policy for Persons with Disabilities, Equal Opportunities and Social Assistance and by the Agency for Persons with Disabilities, is responsible for coordination and implementation of the government policy on the rights of persons with disabilities. 34 Ibid. 36 • The Monitoring Committee is an independent body, in charge of promoting, safeguarding and monitoring the implementation of the Convention on the Rights of Persons with Disabilities. At the regional and local level: • Coordinators are officers from the central and territorial executive bodies, who are assigned additional functions to coordinate policies and programs and measures pertaining to the rights of persons with disabilities. • Regional Councils assist and support regional governors in the implementation, analysis, development of strategies, plans, measures, and other activities pertaining to the implementation of the policy on the rights of persons with disabilities at the regional level. The state35 and local authorities adopt laws, decrees, orders, strategies, programs, standards, and other regulatory documents related to disability policy and the rights of persons with disabilities. The Act also establishes that national and local authorities, together with national representative organizations of and for persons with disabilities, national representative organizations of employers, workers and employees participate in implementing government disability policy by creating enabling conditions for implementation of relevant programs and projects. While the Ministry of Labor and Social Policy (MLSP) is responsible for implementing and coordinating disability policy, Territorial Medical Expert Commissions (or the National Medical Expert Commission in case of a complaint) under the Ministry of Health determine/certify disability (by performing medical expertise). The medical expertise is organized and managed by the Minister of Health and the Regional Health Inspectorate. Disability determination is a precondition for access to disability benefits and services (Figure 2.2). Figure 2.2: Government agencies responsible for disability determination and provision of disability related benefits and services in Bulgaria Ministry of Ministry of Health Labor and Social Policy National Medical Expert Commission National Social Social Territorial Employment Security Assistance Medical Expert Agency Institute Agency Commission Source: Prepared by the World Bank team. 35 National Assembly (Bulgarian Parliament), the Council of Ministers, ministers, etc. 37 2.2.2 Main roles and responsibilities of key institutions 2.2.2.1. Council of Ministers The Council of Ministers36 is a central body of the Government responsible for the development and implementation of national social, economic, defense, security, and other policies. It is the chief executive body overseeing all national policy areas.37 It consists of the Prime Minister of Bulgaria, Deputy Prime Ministers, and ministers. In carrying out its duties, the Council of Ministers collaborates with the National Assembly, the President, the Ombudsman, the Constitutional Court, the judiciary, and other state institutions not included in the system of executive power, as well as with local self- government bodies. It governs and implements internal and external policies in compliance with the Constitution38 and the laws. 2.2.2.2. National Council on Persons with Disabilities The National Council on Persons with Disabilities under the Council of Ministers (NCPD)39 was set up for the purpose of cooperation in developing and implementing the policy on the rights of persons with disabilities. It is chaired by a Deputy Prime Minister. The NCPD interacts with the coordinating and monitoring bodies set by the Persons with Disabilities Act,40 which are responsible for the development and implementation of the policy on integration of persons with disabilities. Figure 2.3: The National Council for Persons with Disabilities ’ structure Source: The National Council for Persons with disabilities website NCPD is an advisory body composed of government representatives nominated by the Council of Ministers, national representative organizations of and for persons with disabilities, national representative organizations of workers and employees, national representative organizations of 36 https://www.gov.bg/bg 37 Public Administration Characteristics and Performance in EU 28: Bulgaria, European Commission, 2018. https://op.europa.eu/en/publication-detail/-/publication/15cd2969-9605-11e8-8bc1- 01aa75ed71a1/language-en 38 https://www.wipo.int/edocs/lexdocs/laws/en/bg/bg033en.pdf 39 http://saveti.government.bg/web/cc_11/1 40 These bodies are: The Ombudsman of the Republic of Bulgaria, The Commission for Protection against Discrimination, The Agency for Social Assistance, the Agency for Persons with Disabilities, The Employment Agency, organizations of persons with disabilities, employees, etc., as well as international organizations. 38 employers and the National Association of Municipalities in the Republic of Bulgaria (Figure 2.3). The appointment, description of NCPD procedures and decision making are established by the Rules adopted by the Council of Ministers.41 All drafts of normative acts, strategies, programs, plans and other acts, which affect the rights of the persons with disabilities are adopted after an opinion of NCPD had been received. NCPD functions, include:42 (i) support and assist the Council of Ministers in designing and implementing policies on integration of persons with disabilities, (ii) discuss and adopt opinions on the drafts of normative acts concerning rights or integration of persons with disabilities, (iii) assist with and promote coordination between the state, municipal, public and economic bodies and institutions and the non-governmental organizations of persons with disabilities and support implementation of their activities on integration of persons with disabilities, (iv) interact with other bodies for the purpose of cooperation, coordination and monitoring issues affecting the rights of persons with disabilities, (v) establish and maintain relations with international governmental and non-governmental organizations for persons with disabilities, and (vi) raise awareness on issues related to the integration of persons with disabilities through active cooperation with media.43 2.2.2.3. Monitoring Committee The Monitoring Committee (MC) is an independent body established in 2019 to promote, safeguard and monitor the implementation of UNCRPD in Bulgaria.44 Figure 2.4: The Monitoring Committee ’s structure CHAIRPERSON (Ombudsman or CPD) 2 representatives - 2 representatives - Ombudsman CPD 4 representatives - 1 representative - organizations of and Bulgarian Academy to people with of Science disabilities Source: The Monitoring Committee website 41 A Decree of the Council of Ministers, № 151 from 14 June 2019 on the “Adoption of rules for the activities and organization of work of the National Council for Persons with Disabilities, the procedure for recognition of national representation of organizations for persons with disabilities and monitoring of compliance with the national representation criteria”. https://dv.parliament.bg/DVWeb/showMaterialDV.jsp;jsessionid=914DCA1EBBB66CB3AEBFA566B0B1D18D?id Mat=138619 42 Ibid. 43 http://saveti.government.bg/web/cc_11/1 44 The Persons with Disabilities Act. https://www.lex.bg/bg/laws/ldoc/2137189213 39 The MC consists of 9 members as follows: two representatives appointed by the Ombudsman, two representatives appointed by the Chairman of the Commission for Protection against Discrimination (CPD), four representatives appointed by organizations of and for persons with disabilities, and one representative of the academic community, appointed by the Bulgarian Academy of Science (Figure 2.4). MC independently adopts its rules for operation and organization and annual work program, and submits annual reports to the National Assembly. The Committee’s duties include: (i) issuing opinions, recommendations and proposals to the institutions in charge of preventing and suspending any violations of the rights of persons with disabilities; (ii) preparing annual reports on the actions undertaken to implement UNCRPD; (iii) reviewing national laws, practices and draft regulations and assessing their compatibility with the provisions of UNCRPD; and (iv) pursuing activities related to promoting, safeguarding and monitoring implementation of UNCRPD. 2.2.2.4. Commission for Protection against Discrimination Commission for Protection against Discrimination (CPD)45 is a national equality body of Bulgaria. It was established in April 2005 under the Law for Protection against Discrimination46 with a main objective “to prevent discrimination, to protect against discrimination and to ensure equal opportunities”. The Commission has its own regional representatives. It submits a report on its activities to the National Assembly by 31 March of each year. The Commission can issue legally binding decisions, impose fines and compulsory administrative measures. It is an independent body comprising 9 members out of which 5 including the chairman and the deputy chairman are elected by the National Assembly, while 4 members are appointed by the President of the Republic of Bulgaria. They are members for 5 years. Its main responsibilities include: (i) identifying and investigating violations of equality protection; (ii) taking decisions to prevent and stop violations of equality protection; (iii) providing binding instructions for equal treatment; (iv) appealing against administrative acts adopted in breach of the principles of equality; (v) proposing and recommending to state and municipal bodies to terminate activities, which may violate equality; (vi) giving opinions on draft regulations to bring them in line with the legislation on the prevention of discrimination; (vii) preventing discrimination by making recommendations for adopting, revoking, amending or designing new legislation; (viii) providing independent assistance to victims of discrimination to submit discrimination complaints; and (ix) informing the public through media about violations and measures for protection against discrimination. 2.2.2.5. Ombudsman of the Republic of Bulgaria The Ombudsman is a body protecting the rights of all citizens, including the rights of children, persons with disabilities, minorities, and foreigners. It has a broad scope of powers concerning all citizens’ rights – political, economic, civil, social, and cultural. It intervenes in cases when acts or omissions of the state and municipal bodies and public service providers violate citizens’ rights and freedoms. The Ombudsman of the Republic of Bulgaria is established by the Ombudsmen Act.47 The National Assembly elects both - Ombudsman and Deputy Ombudsman by open ballot and the candidate who 45 https://www.kzd-nondiscrimination.com/layout/ 46 The Law on Protection against Discrimination. https://kzd- nondiscrimination.com/layout/images/stories/pdf/ZAKON_za_zasita_ot_diskriminaciq_Zagl_izm_DV_br_68_ot _2006_g.pdf 47 The Ombudsman Act. https://www.ombudsman.bg/pictures/Ombudsman%20Act%20EN.pdf 40 received a majority of more than half of the members of the assembly is elected for the position. The Ombudsman has immunity as a Member of the National Assembly. In carrying out her/his duties, the Ombudsman must be independent and should be subject only to the Constitution, laws, and ratified international treaties, to which Bulgaria is a party, being guided by her/his personal conscience and ethics.48 The Ombudsman’s main responsibilities are inter alia to: (i) receive and investigate complaints concerning violation of rights and freedoms by the state and municipal bodies and their administrations, as well as by public service providers; (ii) propose and recommend to the relevant bodies and their administrations actions to restore violated rights and freedoms; (iii) mediate between administrative bodies and individuals to overcome violation and reconcile their positions; (iv) propose and recommend actions to eliminate violation of rights and freedoms; (v) apply to the Constitutional Court if there is a need to clarify constitutional provisions or their compatibility with international treaties to be ratified; (vi) provide opinions to the Council of Ministers and the National Assembly on draft laws concerning protection of human rights; and (vii) protect the rights of children.49 2.2.2.6. Coordinators of the rights of persons with disabilities Coordinators of the rights of persons with disabilities are officers of the executive central and territorial bodies (ministries and municipalities) who in addition to their main obligations under the employment contract, perform the following tasks: (i) develop policies and programs on the rights of persons with disabilities; (ii) contribute to the drafting, implementation and reporting of/on regulations, strategic documents, plans, projects; (iii) analyze and report on the rights of persons with disabilities, in line with the competence of the body concerned; (iv) coordinate implementation of measures within the competence of the relevant body and contribute to the drafting of reports related to the rights of persons with disabilities; and (v) coordinate collection and dissemination of information and best practices related to the rights of persons with disabilities within the competence of the relevant body.50 2.2.2.7. Regional councils Regional Councils are established by regional governors (appointed by the Council of Ministers). They assist and support regional governors in the implementation, analysis, development of strategies, plans, measures, and other activities concerning the implementation of the policy on the rights of persons with disabilities at the regional level. The Councils comprise representatives of regional and municipal administration, nationally representative organizations of and for persons with disabilities, nationally representative organizations of workers, employees and employers, NGOs, and other stakeholders working on the rights of persons with disabilities. 2.2.2.8. Ministry of Labor and Social Policy The Ministry of Labor and Social Policy (MLSP) is responsible for labor and social policy in Bulgaria and persons with disabilities are one of its key constituencies. In addition, MLSP51 coordinates implementation of government policy on the rights of persons with disabilities. In performing its functions in relation to persons with disabilities, the MLSP is supported by the Directorate for Policy 48 Ibid. 49 The Ombudsman deals with individual complaints only, and in many settings have little power other than advisory. 50 The Persons with Disabilities Act. https://www.lex.bg/bg/laws/ldoc/2137189213 51 https://www.mlsp.government.bg/ 41 for Persons with Disabilities, Equal Opportunities and Social Allowances and by the Agency for Persons with Disabilities (Figure 2.5 presents the organizational structure of MLSP). Concerning persons with disabilities, the main responsibilities of MLSP are to: • coordinate activities of the government authorities on the rights of persons with disabilities, • draft, participate in discussions and propose the adoption and/or amendments to regulations, strategic documents, programs, and plans concerning the rights of persons with disabilities, • organize operations of the National Council on Persons with Disabilities (NCPD), • undertake measures required for recognition of the status of nationally representative organizations of and for persons with disabilities, • provide methodological support to executive bodies in pursuing the government policy on the rights of persons with disabilities, • coordinate the collection of data from the relevant institutions and organizations, and prepare analyses and annual reports on the implementation of the rights of persons with disabilities in sectoral policies, • coordinate the fulfilment of national commitments related to the implementation of UNCRPD and of international instruments on the rights of persons with disabilities, • provide information to government authorities and civil society on the implementation of UNCRPD and national policies, • represent the state in international organizations and programs for persons with disabilities, • manage and coordinate participation in national and international programs and projects related to persons with disabilities, jointly with other government authorities and organizations, • maintain contacts with its peer specialized government authorities in other countries, as well as with international organizations in the field of supporting persons with disabilities. Figure 2.5: The Ministry of Labor and Social Policy ’s organizational structure Source: Website of MLSP52 52 https://www.mlsp.government.bg/struktura 42 Specific responsibilities of the MLSP Minister in the field of disability are:53 He/she is a central sole body of the executive power with special competence and manages, coordinates and monitors the implementation of the state policy for persons with disabilities’ integration, social protection, social inclusion, equal opportunities and anti-discrimination, in accordance with the laws of the country and the program adopted by the government; governs, coordinates and controls, in cooperation with other state bodies, social partners and NGOs the analysis, assessment and forecasting of the demographics, equal opportunities, integration of persons with disabilities and anti-discrimination; proposes and implements measures in the areas of competence of the Ministry; controls and coordinates activities of the Agency for Persons with Disabilities, the Social Assistance Agency, and other executive agencies under the Ministry. Within MLSP, several directorates and agencies are particularly relevant for persons with disabilities. The Directorate for Disability Policy, Equal Opportunities and Social Assistance. The Directorate,54 in addition to general functions performed by all MLSP55 directorates, should:56 • develop, coordinate, and monitor and evaluate the implementation of relevant state policies, • organize, coordinate, and participate in the development of relevant normative acts, strategies, programs, action plans, projects and reports and provide observations on good practices, • coordinate, report and analyze the implementation of pertinent strategies, plans, projects, and programs, • participate in the preparation of opinions, positions, analyses, presentations, information, and other documents in the field of integration of persons with disabilities, equal opportunities - gender equality and anti-discrimination, and social benefits, • present and defend the position and interests of the Republic of Bulgaria regarding its participation in the work of committees, institutions, working groups and fora of the Council of the European Union, the European Commission, and the Council of Europe, • support and encourage cooperation with civil organizations with the purpose of their active participation in the process of formulation, implementation, and monitoring of relevant policies, • coordinate the implementation of relevant policies and programs under the responsibility of the Social Assistance Agency, the Agency for Persons with Disabilities and the Social Protection Fund, • prepare opinions for granting subsidies to the nationally representative organizations of and for persons with disabilities for activities to be financed from the state budget, • support the Minister’s participation in the Commission for Protection against Discrimination by providing relevant information, • act as a secretariat of NCPD at the Council of Ministers and provide administrative and technical assistance to the National Council for Equality of Women and Men at the Council of Ministers, • act as Bulgaria’s focal point for UNCRPD (since 2016). The Directorate is managed by a director. It comprises two departments: (i) the Department for Integration of Persons with Disabilities, and (ii) the Department for Equal Opportunities, 53 The Organizational Statute of MLSP, Article 3: https://www.lex.bg/laws/ldoc/2135651037 54 The Organizational Statute of the MLSP, Article 33: https://www.lex.bg/laws/ldoc/2135651037 55 Ibid. 56 https://iisda.government.bg/ras/executive_power/ministry_organigram/87 43 Antidiscrimination and Social Assistance, each of which with its own head and respective state, chief, senior, and junior experts. The Directorate has 16 full-time staff positions. The Social Assistance Agency: The Social Assistance Agency (SAA)57 is an executive agency under MLSP Minister responsible for implementation of the state social assistance policy and for administering and delivering programs to eligible beneficiaries. It is a legal entity based in Sofia, represented and managed by an executive director. The SAA administers policies and programs in social assistance, child protection (adoption, foster care, etc.), and Food Operational Program. Social assistance includes social benefits for individuals and families, children, disabled war veterans and people with permanent disabilities.58 Social assistance is provided in cash and/or in-kind to support individuals and families who are unable to meet their basic needs. Main functions of SAA are inter alia to: • implement state policy on social assistance, • deliver social assistance benefits (programs’ implementation/delivery), • develop a unified system for evaluation and control of the social assistance directorates and conduct specialized control over them through the SSA Inspectorate, • collect, process, store and use data in an integrated information system, • prepare consolidated annual reports on social assistance benefits, • participate in drafting normative acts on social assistance benefits, issue opinions on draft regulation on the rights of persons with disabilities, • improve criteria and indicators for the performance of the individual needs assessments of persons with disabilities in accordance with the Persons with Disabilities Act, • organize individual needs assessments of persons with disabilities in accordance with the procedure stipulated in the Persons with Disabilities Act, • analyze and provide aggregated data on individual needs assessments of persons with disabilities in accordance with the Persons with Disabilities Act and the outcomes thereof, • publish information on its official website, including guidelines, assessment, and evaluation reports regarding the fulfilment of the rights of persons with disabilities, • establish, administer and maintain an integrated information system of the Agency for implementation of activities under law in the field of social assistance, social services and child protection. 57 https://asp.government.bg/ 58 Social services and social benefits provided to individuals and families depend on benefit specific eligibility criteria. Thus, persons with disabilities would qualify if they meet stipulated eligibility criteria. See Chapter 5 on disability benefits. 44 Figure 2.6: The Social Assistance Agency organizational structure EXECUTIVE DIRECTOR Inspectorate Internal Audit Directorate Financial Control Security of Information Employee Protection of Personal Data Officials Deputy Deputy Deputy Secretary Executive Executive Executive General Director Director Director Specialized Administration General Administration International Cooperation, Programmes and Financial and Economic Activities and Property European Integration Directorate Management Directorate Child Protection Directorate Analysis and Administrative Services Directorate Legal Services and Public Procurement Social Inclusion General Directorate Directorate Information Systems Directorate Social Inclusion Reginoal Social Inclusion Directorate Human Resources and Public Relations Directorate Directorate Source: Social Assistance Agency website The structure of SAA (Figure 2.6) includes: General Administration with four directorates, Specialized Administration with one general directorate and two specialized (regional) directorates. The Social Inclusion (Assistance) General Directorate coordinates, supports and operatively manages activities of the territorial divisions (regional directorates for social inclusion/assistance) and the social Inclusion/assistance directorates). The General Directorate: (i) provides methodological guidance on the provision of social, targeted and family benefits, the assessment of the needs for social services, planning, creation, provision and development of social services, exercising the rights of persons with disabilities, and the creation of conditions for employment of the unemployed persons assisted by social benefits; (ii) participates in the preparation of drafts of normative acts on social assistance, social services and the rights of persons with disabilities; (iii) prepares opinions for the implementation of normatively regulated functions in the field of social services; (iv) develops instructions and methodical material on the application of normative acts in the field social assistance, the assessment of the needs for social services, planning, creation, provision and development of social services, as well as the rights of persons with disabilities; (v) participates in the development of concepts and strategies for social protection and social inclusion of groups at risk; (vi) inspects and answers to complaints, inquiries and proposals in the field of social assistance and the rights of persons with disabilities; (vii) provides consultations to citizens and legal persons on issues of social assistance and the rights of persons with disabilities; etc. The Regional Directorates for Social Inclusion/Assistance and the Social Inclusion/Assistance Directorates are the SAA’s territorial divisions in each district center. The Regional Directorates for Social Inclusion/Assistance should: (i) implement state social assistance policy, targeted benefits, family benefits for children, child protection benefits, and assistance to persons with disabilities in the district in cooperation with state bodies, district administrations, local governments and civil society organizations; (ii) coordinate and control activities of the Social 45 Inclusion/Assistance Directorates; (iii) administer, coordinate and control accounting of the Social Inclusion/Assistance Directorates; (iv) provide methodological assistance to the Social Inclusion/Assistance Directorates for: a) provision of social and targeted benefits and family benefits for children; b) preparation of the individual needs assessment and exercise of the rights of persons with disabilities; c) child protection measures; d) implementation of employment programs; (v) study the needs of the population in the field of social benefits and social services, coordinate activities for planning and development of social services at the regional level and participate in the development of the strategy for the development of social services at the district level; etc. The Social Inclusion/Assistance Directorates should: deliver social assistance to families and children, implement child protection policies, deliver social support to persons with disabilities on the territory of respective municipalities in cooperation with other the state bodies, regional administrations, local self-government bodies and civil society organizations; prepare an individual assessment of the needs of persons with disabilities; perform activities related to the exercise of the rights of persons with disabilities. The Inspectorate is an administrative body directly under the SAA’s Executive Director, which exercises specialized control over the application of the normative acts in the field of social assistance, including in relation to persons with disabilities. Figure 2.7: Assessment of individual needs in Bulgaria Ministry of Labor and Social Policy Ministry of Health Social Assistance Agency National Medical Expert Commission Appeal Regional Social Assistance Directorate Territorial Medical Expert Commission Source: World Bank Team. Support to persons with disabilities provided by SAA includes monthly financial support, which depends on the degree of disability, targeted assistance depending on the type of disability, free annual electronic vignette, and assistance to disabled war veterans and war victims (see Chapter 5 on disability benefits). The Persons with Disabilities Act regulates that person with disabilities are entitled to financial support depending on their needs as defined in an assessment of individual needs. This assessment is conducted by a specialized department in the Social Assistance Directorates of the Social Assistance Agency (Figure 2.7). In Bulgaria, municipalities are responsible for delivering personal assistance and other social services to eligible beneficiaries, including persons with disabilities. The needs assessment indicates which services a person with disability needs. 46 The Agency for the Quality of Social Services is a budget-supported legal entity under MLSP Minister, whose key function is to ensure the quality of social services, including services for persons with disabilities. The Agency: monitors provision of social services, licenses providers of social services, makes proposals to MLSP on the development of standards and criteria for quality and efficiency of social services, provides methodological support for compliance with established standards and criteria for quality of social services, etc. The Agency for Persons with Disabilities (APD) is an executive, budget funded legal entity under the MLSP Minister. It is especially dedicated MLSP executive agency responsible for the implementation of some aspects of the state policy on the rights of persons with disabilities.59 It is also part of the coordination mechanism for disability policies in Bulgaria. APD organizational structure and the number of staff are proposed by the Minister of Labor and Social Policy and adopted by the Council of Ministers. Its main office is based in Sofia and additional 6 offices are distributed across the country. The executive Director is assigned by the Minister of Labor and Social Policy jointly with the Prime Minister. APD performs the following functions:60 • participates in coordination mechanism on the policy on the rights of persons with disabilities, • keeps and maintains an information system on persons with disabilities,61 • prepares and submits to MLSP biannual and annual reports on the implementation of the policy on the rights of persons with disabilities, based on the data provided by ministries and institutions, • keeps and maintains a register of a) specialized enterprises and cooperatives of persons with disabilities; b) providers of technical aids and medical devices to persons with disabilities, • supervises provision of technical aids and medical devices to persons with disabilities, • develops programs and finances measures to a) stimulate economic capability and the business to the interest of persons with disabilities; b) finance projects for rehabilitation, social integration, and creation of accessible environment for persons with disabilities, • finances targeted programs for: a) specialized enterprises and cooperatives of persons with disabilities; b) employers; c) establishment and development of independent economic activity of persons with disabilities; d) establishment of centers for sheltered employment, • reimburses costs of measures62 for persons with disabilities implemented by employers, specialized companies, and cooperatives of disabled persons, • determines annually the amount of the funds needed for projects under APD, • participates in drafting normative acts pertaining to the rights of persons with disabilities and provides opinions on drafts by other institutions, • publishes on its website information and guidelines for realization of the rights of persons with disabilities, • reports to responsible authorities the violation of rights of persons with disabilities, • performs other activities determined by laws or by acts of the Council of Ministers. 59 Article 10 paragraph 1 of the Persons with Disabilities Act. https://www.lex.bg/bg/laws/ldoc/2137189213 60 The Statute of the Agency for Persons with Disabilities. https://www.lex.bg/bg/laws/ldoc/2135497051 61 The information system contains data about persons with disabilities’ health status, qualifications, educational degrees, personal capabilities of social inclusion, career, socioeconomic status, etc. Various institutions at the central and local level working with persons with disabilities are obliged to provide up to date data to APD. 62 These measures include ensuring accessibility of permanently disabled person's workplace; adapting a permanently disabled person's workplace; equipping a permanently disabled person's workplace; qualification and requalification, or training for professional and career development. 47 APD is managed by an Executive Director who represents, manages, coordinates, and controls the implementation of the overall activity of the Agency, as well as its relations with other bodies and organizations. It has two departments, namely the Directorate for Persons with Disabilities Full Inclusion and the Administrative, Legal, Financial and Information Directorate. It is staffed with 26 full- time employees. According to the Persons with Disabilities Act,63 APD should be transformed into a state agency on January 1, 2022.64 The State Agency for Persons with disabilities will be a legal funded by the budget of the Council of Ministers with headquarters in Sofia. It is currently envisaged to organize the implementation of the individual assessment of the needs of persons with disabilities and to coordinate the implementation of the policy on the rights of the persons with disabilities. The State Agency for Persons with disabilities will be the legal successor of the assets, liabilities, archives, rights, and obligations of the current Agency for Persons with disabilities. The Employment Agency (EA)65 is an executive agency under MLSP Minister responsible for the implementation of state active labor market policies (ALMPs) and for providing labor market intermediation services. The EA implements programs for persons with permanent disabilities and, together with other stakeholders, develops and proposes measures to ensure equal opportunities through socioeconomic integration of people with permanent disabilities, in accordance with the Employment Promotion Act.66 EA core functions are: (i) to implement projects and programs in the field of employment, vocational guidance and training for adults, social inclusion, and equal treatment programs, funded by the European Union funds or other international sources;67 and (ii) to implement state policy on employment promotion and employment intermediation services.68 Regional Employment Service and Labor Office Directorates are territorial divisions of EA. Territorial units of EA should provide specialized recruitment intermediation for job seekers with disabilities, which includes an assessment of their professional skills; an assessment of wishes and possibilities for acquiring professional skills based on labor market situation; inclusion in a program/project for acquiring professional skills; support for training and onboarding through work mentors; referral of persons with disabilities to potential employers in line with the requirements for intermediation in negotiations between permanently disabled people and employers, regarding the implementation of the regulated quotas for hiring permanently disabled staff. 63 The Persons with Disabilities Act. Transitional and Final Provisions. https://www.lex.bg/bg/laws/ldoc/2137189213. The date was subsequently changed to January 1, 2023. 64 According to Article 54, Paragraph 1 of The Law on Administration , an executive agency is "an administration under a minister for the provision of administra tive services to natural and legal entities”. An executive agency can be established by law or by a decree of the Council of Ministers and is subordinated to a minister to assist him in carrying out specific activities. A state agency is an administrative structure directly subordinated to the Council of Ministers for the development and implementation of a policy for which no ministry has been established. It can be established by a decree of the Council of Ministers, which determines the manner of functioning and the necessary administrative organization for carrying out its activities. See: https://www.lex.bg/laws/ldoc/2134443520. 65 https://www.az.government.bg/ 66 The Employment Promotion Act. https://www.lex.bg/laws/ldoc/-12262909 67 The Statute of the Employment Agency. https://www.lex.bg/laws/ldoc/2135486522 68 The Employment Promotion Act. https://www.lex.bg/laws/ldoc/-12262909 48 2.2.2.9. Ministry of Health Through the Ministry of Health (MOH), the Bulgarian state guarantees protection of the citizens’ health, equality in the use of health services and affordable and quality health care.69 The MOH finances certain medical services outside the scope of mandatory health insurance provided by the state and municipal medical establishments.70 These include recreation and rehabilitation of war invalids and war victims; inpatient treatment, daily psychological rehabilitation programs and rehabilitation through occupational therapy for people with mental illness; diagnosis, treatment and specialized care for children at high medical risk, outside the scope of compulsory health insurance; treatment of patients with active tuberculosis; and medical expertise (certification of disability) carried out by the medical expertise commissions. In compliance with the Persons with Disabilities Act, persons with disabilities are entitled to a comprehensive rehabilitation, which may be medical, professional, social, occupational, and psychological. The Minister of Health is a central sole body of executive power with special competences. She/he inter alia conducts the state healthcare policy, develops, and monitors the implementation of the national health strategy and manages, coordinates and monitors activities for promotion and protection of citizens’ health and prevention of diseases. She/he takes measures for health protection of children and persons with physical disabilities and mental disorders.71 As noted above, MOH is responsible to organize and deliver medical expertise in Bulgaria (i.e., a disability certification/determination service). MOH has established two bodies for this purpose: The National Medical Expert Commission (NMEC) and Territorial Medical Expert Commissions (TMEC). The NMEC and TMEC functioning is regulated by the Ordinance on Medical Expertise72 and the Rules for the Structure and Organization of the Medical Examination’s Bodies and of the Medical Examinations’ Regional Files.73 Their functions and organization are briefly presented below (for detailed discussion, see next Chapter). There are 71 TMECs covering Bulgaria and one NMEM based in Sofia. Territorial Medical Expert Commissions (TMECs)74 certify persons for permanent incapacity for work, and type and degree of disability. TMECs consist of at least three medical doctors from the state and municipal hospitals, subordinated to the Regional Healthcare Departments (regional structures) of the Ministry of Health. 69 The Health Act Article. https://www.lex.bg/laws/ldoc%20/2135489147 70 Ordinance № 3 of 5 April 2019 for medical activities outside the scope of compulsory health insurance subsidized by the Ministry of Health and criteria and conditions for extending the subsidy to medical establishments providing them. 71 The Organizational Statute of the Ministry of Health. https://www.lex.bg/bg/laws/ldoc/2137192109 72 Ordinance on Medical Expertise adopted in a resolution of the Council of Ministers № 120/2017. https://www.lex.bg/bg/laws/ldoc/2137150573 73 The Rules for the Structure and Organization of the Work of the Medical Examination Bodies and of the Medical Examinations’ Regional Files. https://www.lex.bg/bg/laws/ldoc/2135677394 74 http://www.telk.info/ 49 Figure 2.8 : Territorial Medical Expert Commission (TMEC) structure In cases of medical examination for accepting or Territorial Expert rejecting the occupational Technical Medical nature of the disease the Assistants’ following specialists are Commissions Team included and chair the - at least three meetings: occupational doctors including a medicine, Chairperson - radiobiology or radiation hygiene - occupational diseases with recognized medical specialty recommended in: internal medicine, orthopedics and traumatology, surgery, nervous diseases, neurosurgery, urology, medical oncology, eye diseases, pulmology, psychiatry or pediatrics and at least 5 years of work experience in medicine. Source: Articles 11 and 12 of the Rules for the Structure and Organization of the Work of the Medical Examination Bodies and of the Medical Examinations’ Regional Files 75 They assess: i) the type and level of disability; ii) the need for assistance by another person; iii) temporary or permanent limitation/loss of work capacity; iv) the link between disability and the profession/job of the person, f) working conditions, which are appropriate for the person; and g) the ability of a person to continue working in the same job. Since October 15, 2020, referrals to TMECs, issued by general practitioners, are received through the Information System “Medical Expertise” (ISME).76 Figure 2.8 presents the TMEC’s structure. The National Medical Expert Commission (NMEC)77 is an independent legal entity of MOH. NMEC has a control and reviewing function78 related to other medical expert bodies. It investigates and decides on appeals related to the TMECs’ decisions. NMEC has 12 specialized teams for various health conditions (Figure 2.9). Patients are examined in different forms (depending on their diseases), and the decisions of NMEC are made after considering the opinion of each relevant team. Decisions of NMEC may be appealed by the interested persons and bodies (a person, insurers, National Social Security Institute, SASS, APD, and medical bodies) to the administrative court, in accordance with the Administrative Procedure Code.79 NMEC participates in the preparation of medical examination normative acts and provides training to physicians working in medical expert institutions across the country. 75 Ibid. 76 The system was created by MOH while implementing the project "Development, implementation and maintenance of an Information System for monitoring of medical expertise". It is supposed to ensure traceability and high level of control over the submission and processing of documents for medical certification and re- certification of citizens; it also maintains electronic profiles of all persons who have been or are subject to medical expertise. 77 https://nelk.bg/ 78 NMEC prepares a plan and carries out an audit of TMECs decisions, according to the criteria established in the Ordinance on the Medical Expertise. https://www.lex.bg/bg/laws/ldoc/2135677394 79 The Administrative Procedures Code. https://www.lex.bg/laws/ldoc/2135521015 50 Figure 2.9 : The National Medical Expert Commission structure DIRECTOR Information Administrative and Services, Data Medical Examination Legal Department Financial Controller Economic Protection and Department Department Information Analysis Unit Mental, Internal and Cardiovascular Diseases Internal, Pulmonary and Cardiovascular Diseases Neurology, Otorhinolaryngology and CVDs Specialized Neurology, Ophthalmology and CVDs Teams Surgery, Orthopedics and CVDs Pediatric Specialist Occupational Medicine Specialist Source: The National Medical Expert Commission website 2.2.2.10. National Health Insurance Fund The National Health Insurance Fund (NHIF)80 administers mandatory health insurance in Bulgaria. It is a legal entity that consists of a Central Office with headquarters in Sofia, and regional structures called the Regional Health Insurance Fund in each of the 28 regional centers of Bulgaria. The main goal of the NHIF is to ensure and guarantee free and equal access to health care for insured persons. The Ministry of Health and NHIF regulate funding of technical aids and medical devices for persons with disabilities.81 2.2.2.11. National Social Security Institute The National Social Security Institute (NSSI)82 is a public institution that administers state social security in Bulgaria.83 The NSSI administers compulsory insurance in cases of sickness and maternity, unemployment, accidents at work and occupational diseases, disability, old age, and death. NSSI was established in 1995 under the Law on the Social Security Fund84 as the legal successor of the General Directorate of Social Security. NSSI reports its work to the National Assembly of the Republic of Bulgaria. A Supervisory Board composed of representatives of the state and nationally represented association of employers is the governing body of NSSI. NSSI has a Central Office with headquarters in 80 http://www.en.nhif.bg/ 81 MLSP in coordination with the Minister of Health endorses the lists of technical and medical aids for persons with disabilities. 82 https://www.nssi.bg/aboutbg 83 The Social Security Code. https://www.lex.bg/bg/laws/ldoc/1597824512 84 The Law on the Social Security Fund. https://www.lex.bg/laws/ldoc/2135605211 51 Sofia and territorial divisions in each of the 28 regional centers of the country. The application for a pension is regulated by the Procedure for Granting Pensions.85 2.2.2.12. State Agency for Child Protection The State Agency for Child Protection is a specialized body under the Council of Ministers whose main tasks are to: (i) coordinate institutions and organizations working in the field of child protection; (ii) monitor and control compliance with the rights of the child; (iii) manage day to day operations of the National Council for Child Protection. Its administration organizes inspections for compliance with the rights of the child by all state, municipal and private schools, kindergartens and nurseries, medical establishments, Social Assistance Directorates, and relevant civil society organizations active in child protection. The Agency’s chairman is defined as a specialized body of the Council of Ministers responsible for coordination and monitoring implementation of policies in child protection.86 The Agency’s administration assists the Chairman in exercising her/his powers, provides technical support and provides administrative services to citizens and legal entities.87 2.3 Key messages Before we present the key messages from this Chapter, Table 2.1 summarizes key legal acts and key institutions pertaining to the development and implementation of the disability system and policies in Bulgaria. Table 2.1: Bulgaria: Mapping legal and institutional framework Key legal acts Constitution Persons with Disabilities Act Health Act Anti-Discrimination Act, Social Services Act, Child Protection Act, Personal Assistance Act Social Security Code Labor Code Health Insurance Act Employment Promotion Act Who develops policy? Council of Minsters Ministry of Labor and Social Policy Ministry of Health Other institutions and organizations Who is responsible for adopting national National Assembly policy regulations and regulatory acts to Council of Minsters implement the policies? Who implements the national policies? Ministry of Labor and Social Policy Ministry of Health 85 The procedure is based on the Social Security Code, the Ordinance on pensions and length of service, Ordinance on the categorization of labor in retirement, and the Administrative Procedure Code. https://sacp.government.bg/; https://www.nssi.bg/forusers/procedures/167-procesotppensii/682-ropp. 86 The Child Protection Act. https://www.lex.bg/bg/laws/ldoc/2134925825 87 The Statute of the State Agency for Child Protection. https://www.lex.bg/bg/laws/ldoc/-12311545 52 Agency for persons with disabilities Social Assistance Agency Employment Agency National Social Security Institute National Health Insurance Fund National and Territorial Expert Medical Commissions Municipalities Regional Councils Other line ministries Other institutions and organizations Who coordinates national policies? Ministry of Labor and Social Policy Agency for persons with disabilities Coordinators of the rights of persons with disabilities Regional councils Who is responsible for monitoring national Ministry of Labor and Social Policy disability policy implementation? How are persons with disabilities included in National Council on Persons with Disabilities under the national policy development? Council of Ministers Who is responsible for the protection of Monitoring Committee rights of persons with disabilities? Commission for Protection against Discrimination Ombudsman of the Republic of Bulgaria Who is the focal point for the UNCRPD Ministry of Labor and Social Policy/ Directorate for Disability implementation? Policy, Equal Opportunities and Social Assistance Who is responsible for monitoring the Monitoring Committee implementation of the UNCRPD? Source: Compiled by the World Bank staff 2.3.1 Legal Framework Bulgaria presents a good practice example of efforts to make national legal framework sensitive to disability and disability rights and inclusion. Since the ratification of UNCRPD in 2012, Bulgaria has made significant efforts to systematically include disability into its legal framework, from the Constitution to various laws to secondary legislation. The basic tenets of disability inclusion have been respect for and protection of human rights of persons with disabilities, non-discrimination, and policies to support persons with disabilities and ensure their inclusion and participation in all aspects of life. Efforts have been made to ensure that persons with disabilities are included in all aspects of the public policy development, implementation, and monitoring. One of the recent changes is the introduction of an individual assessment of needs to which each person with disability has the right. Both a mainstreaming approach – ensuring that persons with disabilities have equal access to mainstream services like everyone else, and specific provisions – to ensure that mainstreaming is possible, have been employed. 53 2.3.2. Institutional framework Reflecting changes in legal provisions, institutional framework for disability system and policies has been strengthened. Here too, a two-track approach has been followed. Mainstreaming: responsibilities concerning the rights of persons with disabilities and their participation and inclusion have systematically been added to central, regional, and local government bodies and agencies. In addition, new institutions have been established, such as Monitoring Committee, National Council on Persons with Disabilities, MLSP Directorate for Disability Policy, Equal Opportunities and Social Assistance, Agency for Persons with Disabilities, Coordinators of the Rights of Persons with Disabilities and Regional Councils. To strengthen coordination of disability policies development, implementation and monitoring, the Persons with Disabilities Act envisages that the Agency for Persons with Disabilities, currently an executive agency under the MLSP Minister, will be transformed into a state agency (under the Council of Ministers) as of July 1, 2022. Based on the brief review of the institutional framework above, the following is observed: The delineation of functions and responsibilities between different institutions in not always clear : As Table 2.1 shows, multiple government agencies/bodies are involved in performing similar functions. This is fine as long as there is no overlap and duplication, as in principle, efficient and effective implementation of programs requires a clear definition of rules, roles and controls and their methodical implementation.88 It is, hence, advisable to review the function and performance of all institutions involved in disability policy development, implementation, coordination and monitoring, and the relationship between them, and make sure that the allocation of functions is clear and with no overlap. This is particularly relevant for the transformation of the Agency for Persons with Disabilities into a State Agency for Persons with disabilities. Many agencies involved in the implementation of disability policy are a challenge for coordination and efficient and effective implementation. Disability policy implementation is operationalized through numerous programs implemented by sectoral ministries through their specialized departments, autonomous agencies and in collaboration with local administration and self-governing bodies. The challenge regarding implementation is to have an appropriate menu of services and sufficient funding and human resources to implement currently available programs and to ensure that persons with disabilities are systematically included in all programs on equal basis with everyone else. Disability policy has thus far been focused on disability specific policy provisions and institutions specifically dealing with persons with disabilities. Going forward, shifting the orientation towards mainstreaming, would benefit both persons with disabilities and society. Another important challenge is to ensure cross-departmental collaboration in the programs’ implementation at the local level, i.e., the level where the services are provided to beneficiaries (collaboration at the service delivery level). Policy coordination through all phases of public policy making and implementation is one of the most frequently mentioned challenges in public policy. Coordination is a common issue even within the same government entities, let alone in areas such as disability that are cross sectoral and encompass the entire government. Bulgaria has several institutions tasked with coordination of disability policies and programs from national to the local level of government. A review of the work and an assessment of performance of these structures, with a view of strengthening coordination is recommended. Policy monitoring: Monitoring is closely related to the reporting hierarchy and accountability for results and is closely linked to the clarity and delineation of functions. Implementing government 88 For examples of good governance principles, see the 12 principles of the good governance of the Council of Europe. https://www.coe.int/en/web/good-governance/12-principles/ 54 bodies should monitor the implementation of programs for which they are responsible to make course corrections. The ministries should monitor the work of agencies under their authority; however, they themselves are accountable as well, and should report to the relevant national level bodies in their respective policy areas. Finally, the government is accountable to the parliament and ultimately to the citizens. It is therefore important to have clarity concerning who reports to whom, who is accountable to whom and who monitors whom for transparent and effective governance and good results. While there are some elements of monitoring built into the current institutional framework in Bulgaria, overall, disability policy implementation monitoring arrangements, except at the national level, are not entirely clear. Monitoring also seems to be cojoined with implementation, so in one state body one finds policy development, regulation, implementation, and monitoring. While internal monitoring is important, there should also be external monitoring that is separate from policy implementation to avoid a conflict of interest and to ensure accountability for results. We thus recommend that this issue is addressed, and that disability policy implementation and internal and external policy monitoring are clearly defined. We thus recommend: Ensure that the allocation of institutional functions is clear with no overlap . To that end, conduct a comprehensive review of functions and performance of all institutions involved in disability policy development, implementation, coordination and monitoring, and the relationship between them. This is particularly important in the context of the establishment of the State Agency for Persons with Disabilities. Strengthen disability policy development and implementation coordination: Bulgaria has several institutions tasked with coordination of disability policies and programs from national to the local level of government. A review of the work and an assessment of performance of these structures, with a view of strengthening coordination is recommended. Again, this is particularly important in the context of the establishment of the State Agency for Persons with Disabilities. Disability policy development coordination, particularly at the national level is much less of an issue, than ensuring operational collaboration and coordination (that is at the level of implementation, i.e., at the delivery level). One direction to explore to address this problem to introduce a case management approach at the local level (optimally at the social assistance directorates), but also ensuring a much tighter inter-agency collaboration, including through an integrated information system of all agencies involved in the disability policy implementation at the local level. Focus on mainstreaming. A stronger focus on mainstreaming disability is recommended to balance mainstream and disability specific policies. Strengthen monitoring of disability policy implementation . First, internal, and external mechanisms for policy implementation should be clearly defined and separated. Second, a wealth of empirical data Bulgaria collects, which is critical for monitoring, should be accessible to policy makers, academia, and researchers enabling evidence based and transparent monitoring of results. 55 Chapter 3: Disability assessment and certification In Bulgaria In this Chapter we look at the institutional, procedural and methodological details of the temporary and permanent disability assessment and certification system based on medical examination, and in particular the medical expertise instrument and methodology found in the Ordinance on Medical Expertise.89 Disability certification is critically important administrative actions in Bulgaria as it is a necessary requirement to determine eligibility for all benefits and services that are available to persons with disabilities. Like many European countries, Bulgaria has long relied on a purely medical approach to disability assessment. The medical approach effectively assumes that the only evidence required to assess disability is the medical condition of the person – that is the diseases or injuries, and resulting impairments of body function or body structure, that they experience. But, also like many European countries, Bulgaria is beginning the process of moving away from this medical approach to a more relevant methodology for assessing the impact of health problems and impairments on people's actual lives. This methodology is based on the concept of functioning – and problems in functioning, or disability – found in the World Health Organization's International Classification of Functioning, Disability and Health (ICF).90 It is also the conception of disability that is stated in the United Nations' Convention on the Rights of Persons with Disabilities. Indeed, Bulgaria's own Persons with Disabilities Act embodies this conception of disability in its definition of 'people with disabilities'.91 3.1. Introduction Currently in Bulgaria, disability assessment is based entirely on a 'medical expertise' assessment instrument, developed, and managed by the Ministry of Health under the Health Act,92 and conducted by medical professionals and founded entirely on evidence from medical documentation. The medical assessment instrument, and procedures and criteria governing its use, are set out in the Council of Ministers' Ordinance on Medical Expertise (OME)93 and the Rules on the structure and organization of work of the bodies of the medical expertise and of the regional filing cabinets of the medical expertise (RSO).94 The medical expertise instrument itself (found in OME) is a Baremic-style assessment instrument that links health conditions (diseases, disorders, injuries) and selected impairments of body function and structure to levels of severity of disability, represented as percentage of 'whole person' disability. The levels of performance in a person's actual environment of everyday activities, including major life areas such as work, education, or community life, are not considered in the assessment. Disability assessment, in short, does not align with the phenomenon of 'functioning' as described in the ICF. 89 Ordinance of Medical Expertise. https://www.lex.bg/laws/ldoc/2135678969 90 WHO, International Classification of Functioning, Disability and Health (ICF), WHO: Geneva, 2001. https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health 91 The Persons with Disabilities Act. § 1. 1. "People with disabilities "are persons with physical, mental, intellectual and sensory insufficiency, which in interaction with their environment could hinder their full and effective participation in public life". 92 See Chapter 2. The Health Act (https://www.lex.bg/laws/ldoc%20/2135489147/) stipulates overall principles and criteria for the medical expertise, the procedure for establishing temporary incapacity for work, the type and degree of disability, the degree of permanently reduced work capacity, confirmation of an occupational disease, as well as conditions and procedures for performing the medical expertise. For simplicity, to all of these we refer to as the assessment (and certification) of disability. 93 Ordinance on Medical Expertise adopted in a resolution of the Council of Ministers № 120/2017. https://www.lex.bg/bg/laws/ldoc/2137150573 94 The Rules for the Structure and Organization of the Work of the Medical Examination Bodies and of the Medical Examinations’ Regional Files. https://www.lex.bg/bg/laws/ldoc/2135677394 56 Disability Assessment is the primary decision-making factor for the determination of temporary and permanent incapacity to work (for working age adults), eligibility for disability pension (under the Social Security Act), for determination of the occupational nature of a disease, and (for children under 16) the determination of the type and degree of disability. The medical expertise used for these determinations is carried out or overseen by either a general practitioner, an attending physician or a dentist, the Medical Advisory Commission (MAC), the Territorial Medical Expert Commission (TMEC) or (mainly for appeals) by the National Medical Expert Commission (NMEC). The circumstances under which one or another of these commissions are involved in the medical examination is described in the National Framework Agreement for Medical Activities (NFAMA), an agreement between the National Health Insurance Fund and the Bulgarian Medical Union.95 The 2018 Persons with Disabilities Act defines 'people with disabilities' as "persons with physical, mental, intellectual and sensory disability, which in interaction with the surrounding environment could hinder these persons’ full and effective participation in public life" and 'persons with permanent disabilities' as "persons with permanent physical, mental, intellectual and sensory deficits which in interaction with the surrounding environment could hinder their full and effective participation in public life, and for whom a relevant authority medical report has established the type and degree of disability of 50 or more percent". It is noteworthy that whereas both definitions explicitly state that disability is the outcome of interactions between health deficits and the surrounding environment (the ICF conception of disability), permanent disability is nonetheless defined in terms of a 50 percent of more degree of disability determined by the medical expertise that does not take the environment into account. 3.2. Institutional Framework for Disability Assessment In this section the institutions involved in the medical examination, decision-making, documentation collection, and certification of disability assessment are described. In general, the Ministry of Health (MOH) and Regional Health Inspectorates (RHIs) are responsible for organizing and managing the medical examination, while the entities that carry out the assessment are called the 'bodies of medical examination', whose powers and responsibilities are stipulated in Chapter 3 of the RSO. The process is monitored and overseen by the National Medical Expert Commissions, the Minister of Health, by the National Health Insurance Fund, the National Social Security Institute, the Regional Health Inspectorate and by the Regional Health Councils.96 (See Annex 1 to this Chapter for further details). The four designated 'bodies of medical examination' and their respective powers are: i) General practitioner, attending physician or dentist – they have the power to assess temporary disability based on "a clinical examination, the results of the performed examinations, the conclusions of the consultants, the nature of work and working conditions of the patient".97 ii) Medical advisory commissions (MAC) have the power to certify persons for an extension of a sick leave due to temporary disability over 14 days and make other decisions with respect to sick leave, such as authorizing the provision of medical devices, technical aids and equipment, and vocational rehabilitation. Grievance with respect to the medical doctor decision, are evaluated by relecant MAC. 95 National Framework Agreement for Medical Activities. https://www.nhif.bg/get_file?uuid=9CE5C398732226B9E05400144FFB42AE 96 Art. 111 of the Health Act. 97 Ibid. https://www.lex.bg/bg/laws/ldoc/2135677394 57 The members of each MAC are appointed yearly by RHIs based on proposals submitted by the heads of medical institutions that had established MACs. Medical institutions may have both general and specialized MACs. A general MAC has a permanent staff of three specialists: neurologist (neurosurgeon), surgeon (orthopedist) and a chairman who is a specialist in internal medicine with over 5 years of experience. Normally, mental health or eye-related diseases, or children under 16 years of age are handled by specialized MACs, although where specialized commissions are not available, these cases are handled by the general MAC with the support of external specialists on these diseases. Specialized MACs can be established for specific medical branches such as cardiology, oncology, obstetrics, and gynecology. The role of specialized MACs can also be played by medical units and clinics and should consist of a minimum of two doctors, one of whom is the chair. Currently there are 2,886 MACs registered in medical institutions across Bulgaria (or one MAC per 2,425 population). iii) Territorial medical expert commissions (TMECs) – are the primary assessment and certification bodies for permanent disability (i.e., temporary and permanently reduced work capacity, and for the determination of the type and degree of disability). They also have the power to determine whether a condition is an occupational disease causally link to a job/workplace, the type and degree of disability for a disability pension, and – for children up to 16 years – the need for medical devices and aids. TMECs consist of at least three medical doctors from the state and municipal hospitals that are governed by the Regional Healthcare Departments of the Ministry of Health. Since October 15, 2020. Referrals to TMECs, issued by general practitioners, are received through the Information System for Control of Medical Expertise (ISFME). TMECs are established by state and municipal medical institutions for hospital care, mental health centers, centers for skin and venereal diseases and complex oncological centers, if they have required expert capacity. Currently there are 69 registered TMECs in Bulgaria, although they are not evenly spread across the country. To establish a TMEC, a head of a medical institution sends a request to a relevant RHI; a director of the RHI consults with the MOH. Medical institutions in which TMECs have been established perform comprehensive medical examinations of the applicants and provide conditions for the TMEC work (office space, inventory, tools, stationery, and transport for the members of the TMEC). To avoid the conflict of interest, TMECs cannot include MAC doctors who have issued the initial expert decision, those who have provided consultations on temporary and permanent disability, or spouses or other relatives of the applicant.98 While these rules are notable, in the same medical institutions, colleagues and friends of the members of the commissions will be unavoidably involved in medical examinations and treatment of patients undergoing the assessment. Moreover, in small towns and cities medical partitioners tend to be well known. Hence hidden biases may well be present in the TMECs deliberations and decision making. There are no specific criteria for TMEC members other than the requirement that doctors have a recognized medical specialty – such as internal medicine, orthopedics and traumatology, surgery, neuro diseases, neurosurgery, urology, medical oncology, eye diseases, pneumology and phthisiology, psychiatry or pediatrics – and 5 years of work experience. Upon joining a TMEC and then every consecutive year, the specialists undergo mandatory training by NMEC on the application of the 98 A medical doctor may not participate in the assessment in the following situations, if she or he: i) took part in the issuance of the appealed TMEC decision; ii) took part in a consultative activity, related to the assessment of temporary incapacity for work, or disability assessment of a particular individual; iii) is a spouse, a relative in a direct line without restrictions or in a collateral line up to the second degree of the person being certified; iv) is married to the person. In any of these situations, the affected commission member must state in writing that she/he will refrain from the participation in the meeting of the commission. The statement should be given to the head of the medical establishment that operates a particular TMEC, or to the director of NMEC (if the certification is conducted by it). Art. 15. of the RSO. https://www.lex.bg/bg/laws/ldoc/2135677394 58 Ordinance and the Regulations for conducting the medical expertise with the Barème tables. During the working sessions of TMECs, when considering individual applicants, doctors with an acquired specialty in the disease profile of the reviewed case may also be consulted. If the commission needs to establish the relationship of an occupational disease to work, an occupational medical specialist will chair the meeting. In addition to TMECs and with the same operational functions are the Central Military Medical Commission at the Military Medical Academy, which assesses disability of military personnel and the Central Medical Expert Commission (CELC) at the Ministry of Interior, which assesses disability of civil servants. To operate a TMEC, a director of a medical establishment as regulated by Article 106a of the Medical Establishments Act must sign a financing agreement with the Minister of Health. For persons covered by health insurance, all costs related to the assessment of disability or work capacity (diagnostic of the health condition, special diagnostic procedures requested by TMEC/NMEC and the work of the TMEC members) are financed by the National Health Insurance Fund (NHIF).99 Persons who are not insured under the Health Insurance Act pay all the cost related to disability assessment by themselves.100 iv) National Medical Expert Commission (NMEC) – has managerial and oversight powers over the process of medical examination for disability assessment, investigates and decides on appeals of the TMEC decisions and has the power to confirm the decision or annul it and order a new medical examination. NMEC is an independent legal entity of the MOH, based in Sofia. It participates in the preparation of medical examination and provides training to physicians working in medical expert commissions across the country. NMEC includes an administrative and economic department, a legal department, a medical assessment department (consisting of specialized medical teams by disease profiles), an office for technical processing of expert decisions, and an office for information, data protection and analysis. NMEC also includes specialized medical teams depending on specific needs. In 2020 there were 12 such teams. Each specialized team consists of at least three medical doctors, one of whom is the chairman. Since 2020, NMEC has had the obligation to create and maintain an information database for all persons who have undergone assessment by TMEC or NMEC, including relevant documentation on which the decision has been made. 99 A medical institution operating TMEC receives annual funding for the TMEC work from the NHIF and the exact amount depends on the number of performed assessments. According to the National Framework Agreement No. RD-NS-01-4 of 23 December 2019, the remuneration per TMEC member per assessment is 10 BGN. https://www.mh.government.bg/media/filer_public/2020/02/04/nrd-rd-ns-01-4-23-12-2019-nzok-bls-2020- 2022.pdf. However, there is no information on how the TMECs’ members are remunerated (normally, they are staff of the medical establishment that operates the TMEC). 100 Article 22, of the Rules for the Organization and organization of the work of the bodies of the medical examination and of the regional files of the medical examination. https://www.lex.bg/bg/laws/ldoc/2135677394. 59 Additional key institutional players in disability and work incapacity assessment are: v) The National Social Security Institute (NSSI) is involved in the permanent disability assessment process for persons covered by social security and when TMEC has certified their disability to be at 50 percent or higher. For such a person to be awarded a disability pension and a supplement for assistance by others, a decision of a medical commission at the NSSI’s territorial division is needed. The NSSI medical commission consists of a chairman and two members, appointed by the head of the territorial division. One of the members must have at least 5 years’ experience in a relevant medical field. The NSSI medical commission reviews medical documentation certifying the health condition of the person, the expert decisions of TMEC or NMEC for determining the degree and duration of disability. The decisions of the medical commission must be made unanimously. The territorial divisions also carry out investigations to determine the causal link to the job/workplace of the person under medical assessment for reduced work capacity. This is done by special commissions, consisting of the NSSI representative acting as a chairman, an occupational medicine specialist, a representative of the Labor Inspection Directorate, representative of the employer, and a representative of the employees’ working conditions group.101 vii) Regional File Offices of the Medical Examination (RFME). These are units within Regional Health Inspectorates (RHI) that handle all documentation related to medical examinations by all four bodies of the medical examination described above, including applications for an assessment, medical documentation, medical expert files, decisions, and certifications. Specifically, these offices handle the registration, processing and archiving of documentation related to applicants for temporary or permanent disability. They also register and forward appeals of TMEC’s decisions to NMEC. Their staff include medical doctors, dentists, and technical contractors according to the number of TMECs in the region and the volume of their work. Documentation is kept for up to 40 years from the time of the latest decision of TMEC or NMEC for permanent disability, and up to 5 years for all other cases.102 3.3. Data on temporary and permanent disability In 2019 according to the NSSI reports, the number of persons having temporary disability due to general illness or non-labor-related injury was 865,974, or about 22.0 percent of all employed persons. Temporary disability due to caring for a sick family member and quarantine was reported by 104,560 persons, while the number of persons with temporary disability due to an accident at work and an occupational disease was 4,687. In total, about 31.0 percent of employees were on a sick leave in 2019 in Bulgaria. This appears rather high. Bulgaria should consider doing an in-depth study on determinants of sick leave. Figure 1 compares annual applications with the number of those who have received TMEC or NEMC decisions for permanent disability. Overall, in 2019, 163,670 persons underwent certification and recertification of disability, of which 159,551(98.0 percent) were assessed as having permanent 101 This is a group of at least 3 employees organized to protect rights of employees and working conditions within a company. They have the status of a non-profit associations and are members of the Confederation of Independent Trade Unions in Bulgaria. 102 RFMEs store medical documents. This data base is new. According to the official information from NMEC, the Information System for Control of Medical Expertise (ISCME), became operational on October 15, 2020. It serves the entire process of certification and re-certification by the bodies of medical expertise. All referrals to TMEC are managed through ISCME. The system was created under the project "Development, implementation and maintenance of an Information System for Control of Medical Expertise" of the Ministry of Health. Its objective is to ensure traceability and a high level of control of the processes of submission and processing of documents for disability certification and re-certification of citizens. https://ibd.mh.government.bg/; https://nelk.bg/на-15-октомври-ще-заработи-информационн/ 60 disability of at least 50.0 percent Most assessments (more than two thirds) were recertifications. 49,587 cases were the first-time certifications. For detailed statistics see Annex 1 to this Report). Figure 3.1: Medical assessment for permanent disability: applications and medical expert decisions 2016-2019 Source: Calculations based on MOH Annual reports and NCPHA. Note: The data does not include permanent disability decisions for children up to 16 years old. For reference, in 2019, 12,812 children received expert decisions on disability, of which 11,122 (87%) received permanent disability; 3,441 (26.9% percent) were assessed for the first time. The number of first-time assessments for children has gradually been decreasing since 2015. 3.4. Medical expertise procedures The Ordinance on Medical Examination governs the principles, criteria, and procedure for the medical determination of the recognized categories of 'disability': temporary and permanent disability, and the qualification for disability pension, as well as the determination of kind and degree of disability for children and the presence of an occupational disease. In addition, the OME also regulates the assessment of the need for assistance from other people, the duration of permanentdisability, an opinion on the causal link between the injury (or death) and working conditions, determination of whether a person can continue performing the job, the, need for employment and related accommodation, etc. The medical expertise (Annex 1 of OME) is only used for permanently reduced work capacity, type and extent of disability, disability pension and determination of occupational disease. These assessments are carried out by TMEC and NMEC. For temporary disability (or incapacity to work - sick leave provisions), the attending physician or dentist relies on medical records and the MAC uses a specially designed and ICD-based medical protocol, the 'Certificate on entitlement to cash benefits for temporary incapacity for work' available from The National Social Security Institute (NSSI). This document is a statement of medical opinion by MAC, typically for diseases in their active or acute phase. 61 (i) Temporary disability (sick leave) less than 6 months Attending physician or dentist If an employed person has an illness, an accident, or a disease (or is caring for a sick family member) that prevents work, he or she undergoes examination for temporary disability determined by attending physician, general practitioner, or dentist. The procedure, described below, may take from 1 day to a month to complete: 1. The person visits his/her general practitioner, attending physician or dentist for examination. The attending physician assesses the medical condition, reviews existing diagnoses and medical results and examines the nature of his/her working conditions. 2. The doctor issues a sick leave for temporary disability to be sent to the employer in the following several days. The doctor prepares a sick leave ambulatory sheet, describing the anamnesis, performed examinations, treatments, diagnosis, epicrisis. The physician also provides his/her opinion on the patient’s ability to work, and the start date and duration of the temporary disability. The doctor may suggest work accommodation to the employer (changed working hours, slight adaptation to the workstation, etc.) for up to 1 month. The doctor gives the sick leave and recommendations in paper to the person. 3. The person submits the sick leave and doctor’s recommendations (if any) to his/her employer with a filled declaration for payment methods. 4. By the 10th of the following month the employer submits a certificate to the NSSI electronically. If the person is self-insured, he/she submits on his/her own the certificate electronically to the NSSI. 5. NSSI releases and pays cash-benefits to the employer or insured self-employed persons. To qualify for a paid sick leave, a person must have at least 6 months of insurance for general illness and maternity and have active insurance coverage. The employer is obliged to pay at least three working days for temporary incapacity for work in the amount of 70% of the average daily gross remuneration for the month. The remaining days are paid by NSSI. In the case of temporary disability due to pregnancy, the cash benefit is fully covered by NSSI. The benefits are paid through the employer, or, in case of self-insurance, directly to a person. Medical Advisory Commission The expert decision for extended temporary disability is made by a MAC of a medical institution: i) if the patient has used continuous sick leave for up to 14 days, or 40 days leave within one calendar year, a longer period for work adaptation is needed or her/his health condition requires a longer period of sick leave; ii) if the person needs provision of medical and other assistive devices and equipment. In either case, the procedure should take around 15-20 days: 1. A person visits a general practitioner, attending physician or dentist who determines that the person needs a prolonged sick-leave or medical device or equipment (a technical aid). The doctor prepares a referral to the appropriate MAC. In the referral he/she provides reasons for the need for a prolonged sick leave or aids, equipment, and medical devices. The person should provide results from other examinations and consultations (if any) to the doctor who prepares the ambulatory sheet with supporting medical documentation such as anamnesis, examinations, treatments, diagnosis, epicrisis and professional opinion. In the case of 62 European citizens from another EU or EEA country, the doctor fills in the form E213,103 requested by the NSSI. All documents are given to the person. 2. The person applies to MAC for examination. The person may choose a MAC to which she/he wants to apply. The doctor may also recommend a MAC in a particular medical institution. 3. The selected MAC checks the documents and conducts a medical examination. 4. MAC prepares a medical protocol104 summarizing the anamnesis, performed examinations, treatments, diagnosis of the primary and other illnesses, epicrisis, opinion on the temporary or permanent disability and specifies additional medical documentation (if any). The specific disease is classified according to the ICD-10. In the medical protocol MAC decides whether the temporary disability will not exceed 180 calendar days per year or 30 days without interruption. In case of request for special equipment and medical devices MAC fills out a different type of protocol105 in which it outlines the types of needed equipment and medical devices. 5. 15 days after making the expert decision the MAC prepares a medical protocol in two originals – one for the person and one for its own archive. (ii) Temporary disability (sick leave) longer than 6 months If temporary disability lasts longer than 6 months without interruption or 12 months with interruptions over two years, and there is evidence that the person will eventually return to work, then a decision to extend temporary disability is made TMEC; the procedure is as follows: 1. Steps 1- 4 as in 3.1 above. 2. Before the last sick leave expires, TMEC carries out a medical examination (and checks the case every 2 months thereafter until the person returns to full capacity or his medical condition leads to permanent disability). 3. TMEC confirms temporary disability and the sick leave within 15 days from receiving the referral from the MAC. The sick leave for temporary disability may be extended after the expiration of the new 6 months only for certain diseases, such as tuberculosis, traumatic injuries, postoperative conditions, hepatitis, or myocardial infarction where it is obvious that the insured will recover in the next 6 months, however the sick leave should not be extended continuously for more than 18 months. (iii) Permanent disability The assessment of permanent disability is performed by TMECs or specialized teams in NMEC. In the case of child disability, a pediatrician is involved. In all cases, the determination is based on the degree of disability in percentages as compared to a healthy person, based on submitted medical documentation "objectifying the degree of disability and functional deficit of the diseased organ and/or system, and if necessary, on the basis of a detailed clinical-expert anamnesis, in-depth clinical examination and targeted laboratory and functional texts".106 Article 63 of OME requires that medical documentation establishes the presence of an impairment, a stage in the development of the 103 E213 is a very detailed standardized medical protocol filled in when the relevant institution requests information for the medical condition of a person applying for disability pension from other country in EU or EEC, in which territory the person does not reside. It is ICD-based. https://eur-lex.europa.eu/legal- content/EN/TXT/PDF/?uri=CELEX:32002D0864&from=BG 104 The medical protocol template is available at http://www.mh.government.bg/media/filer_public/2019/10/25/prilozhenie__9_km_chl_24_al_8.pdf. 105 Protocol is available in the Methodological guidelines of the Minister of Health: https://www.mh.government.bg/media/filerpublic/2015/04/08/metodichno-ukazanielkk17-03-2011.pdf 106 OMC. 63 impairment, and a kind and degree of associated 'functional deficit' that is found as a 'starting point' in the medical expertise (Annex 1 to OME). (If the reported impairment is not listed, but causes a significant functional deficit, TMEC may recognize it as a justified cause of disability.) The overall percentage of permanent disability is determined by a methodology described in the Annex 2 to OME: For a single impairment on the Annex 1 list, the extent of disability is a percentage associated with that impairment. When a person has two or more impairments, a two-step method is used. For the impairments that are 50 or more percent, a disability is assessed as the highest percentage in this group. If there are other impairments, lower than 50 percent, then the first score is increased by adding 20 percent of the sum of the percentages of other impairments. In all cases, a score of 50 percent or more establishes permanent disability or reduced work capacity and a type and a degree of disability. The duration of permanent disability ranges from one to three years depending on the nature of disability, the projected dynamics of its development and the possibilities for recovery. In the cases of health conditions that are chronic and there is no possibility for a full or even partial recovery, lifetime disability can be certified. For those who have acquired the right to a social security old age pension, a lifetime disability pension is certified.107 Although these are lifetime determinations, additional assessment may be carried out at the individual's request or at the request of the control bodies of the medical expertise – NMEC, NSSI or a Regional Health Inspectorate. TMECs and NMEC also determine a need and a period for assistance by others when the degree of permanent disability is higher than 90 percent. In the case of children, the assistance by others can be provided for a degree of disability below 90 percent, depending on the nature of the disease and level of independence. The term may be the same or shorter than the term of reduced work capacity or disability), depending on the health condition and its dynamics, but for not less than 6 months. The working conditions that are specifically contraindicated for the health condition of the person with permanent disability are also determined by TMECs or NMEC. For employed people, workplace adaptation can be suggested, as well. Persons with lower than 50 percent disability may be directed to MAC for the assessment of the need for a workplace adaptation. Procedure for permanent disability (Figure 3.2): 1. Referral to TMEC: a) From general practitioner, attending physician or dentist: These are cases where there was no prior decision of temporarydisability, there was a change in the date, duration of or allowed working conditions in the prior decision for permanent disability, or there was a need for a new expert decision because of a change in the medical condition of the person. In these cases, the general practitioner, attending physical or dentist may consult with other specialists, conduct tests or diagnostics before preparing a referral to TMEC and giving the referral to the person who must submit it to the RFME. b) From MAC: This occurs when the person has been previously evaluated for temporary disability and either i) the person has already used 180 days of continuous sick leave or has had in total 360 days of sick leave in the last 2 calendar years; or ii) there are signs of permanent disability. MAC must refer the person to TMEC 7 days before the expiration of the last sick leave. The person submits to RFME the medical protocol. 107 Article 101а of the Health Act. 64 c) Direct referral: The person or (in the case of a child) a representative may directly apply to TMEC for decision on permanent disability; the application must be submitted through the RFME. 2. Submission to RFME: a. A person or representative applies to RFME with documentation (since October 2020, this is online – the information management system for the medical expertise is discussed in Chapter 7): an ID for the identity check; a birth certificate for children up to 16 years of age; a copy of the power of attorney (if applicable; the original for reference); a certificate from the municipality to confirm her/his current home address (if different from ID); an application form; a referral from a general practitioner or a dentist or the MAC medical protocol; relevant medical documentation (certified copies of medical documents (up to 12 months before the application date) with medical diagnostic tests results and consultations, transcripts of medical histories, epicrisis from hospitals, transcripts of forensic examinations, X-ray, CT and NMR scans; a declaration for storage and processing of personal data, etc. The experts at RFME have three days to make administrative check (formal) of the submitted documentation and check if there is already an existing medical expert file or other documentation for the same person. If the documentation is not complete, they contact the person and request the missing documentation. b. The RFME sends the application and documentation to the assigned TMEC. The chairman of TMEC distributes copies to TMEC members and notifies the person or his/her representatives by a certified letter or certified electronic means whether the commission will rule only based on the submitted medical documentation, without the person’s presence, or a date of the face-to-face interview if further examination is required. c. TMEC decision based on documents only: if the medical documentation is deemed sufficient; for re-determination and appeal of sick leaves; for treatment abroad for more than two months; and if documents are received from another EU country. The Medical Expertise and Medical Expertise Methodology (described below) is used. d. TMEC decision based on the face-to-face interview: ТEMC calls the person for a meeting, which may also include clinical examination. Persons unable to attend because of medical indications are visited by the medical commission and certified at home or at the institution where they are hospitalized. In this case, a medical certificate from the personal physician should be provided. The Medical Expertise and Medical Expertise Methodology (described below) is used. e. TMEC decision. Within 3 months TMEC will discuss the assessment of each doctor and see if there is a disagreement. At the invitation of the chairman, the person, representatives of the employer, representatives of organizations of people with disabilities, and other persons involved in the specific issues related to the determination may participate in the meeting. At the end of the session the expert decision of TMEC is signed by all doctors. In the absence of a unanimous opinion, the expert decision is taken by a simple majority. In the case of a tie, the vote of the chairman of the commission is decisive. f. RFME electronically informs relevant institutions that provide benefits to persons with disabilities (NSSI, NHIF, ASA, APD, etc.), as well the person’s employer and sends the medical experts decision to the assessed person or a representative in a certified mail letter. g. Within 14 days the person or her/his representative may appeal (see below). 65 Figure 3.2: Steps for medical expertise of the type and degree of permanent disability Applications Medical for Benefits Examinations 4 Referral 1 Appointment/ Treatment Healthcare Institution Regional Directorate of SAA (MAC or attending physician) 2 Territorial Unit of NSSI Labor Office Decision e Medical Application for l Fil Examination ica Permanent M ed Disability Certification Documentation Medical File 3 Examination Decision with medical file TEMC of a Medical Institution RFME of the TEMC Regional Health Inspectorate Session Determining the occupational nature of a disease or an impairment This procedure takes about 2 months to complete and has the following steps: 1. A person visits a general practitioner, her/his attending physician or a dentist who makes an initial diagnosis and within 5 days sends a notice to the Territorial Unit (TU) of the NSSI and to the person’s employer. 2. Up to 3 days from the notice, the TU of NSSI performs administrative check to see if all documents are properly prepared. If something is missing or not properly done, corrections are formally requested and received back. 3. The Director of the TU of NSSI issues an order for investigation of the case, which is given to the employer and the Labor Inspection Directorate with a request for additional documentation, if needed. The employer sends all requested documentation. 4. The investigation is carried out by a special commission, chaired by the NSSI, which results in an occupational disease inspection protocol. 5. The special commission sends the protocol to the TU of NSSI, to the person, to the employer and to the Labor Inspection Directorate. 6. The person takes the protocol to the GP for a referral to be assessed by TMEC. 7. GP or MAC prepares the ambulatory sheet with the supported medical documentation and professional opinion regarding occupational disease and provides referral (medical protocol in case of MAC) to the person for TMEC. 8. The person submits his/her application to the RFME in paper with the following documents: copy of ID; medical referral of the GP or medical protocol of MAC; work description filled in by the employer; results from clinical examination: medical file data and a protocol for the inspection of occupational disease. 9. RFME sends the application and the medical file of the person to the respective TMEC, which reviews the documentation and may request the person to undergo further examinations by occupational disease units and clinics. 66 10. In 15 days, TMEC holds a session with the person. In the case of a positive decision, TMEC certifies the occupational nature of the disease. Often, the person’s disability had already been determined through a medical assessment. The TMEC fills in a registration card for a recognized occupational disease in four copies, and sends them to NSSI, RHI, The National Center for Public Health and Analysis, and the District Labor Inspectorate. TMEC also issues expert decision on the type and degree and duration of disability to the person. After the duration of the certificate has expired, the person needs to apply again for disability certification by TMEC or NMEC and undergo the same steps. If the person is employed, the employer may be obliged to provide workplace accommodation or to provide a new job placement for the employee within the. 3.5. Medical expertise of disability – methodology and instrumentation The Ordinance for Medical Expertise (OME) sets out the principles and criteria for a medical expertise. Annexes 1 and 2 specifically provide the medical expertise, Barème instrument that matches diseases and associated impairments with percentages of disability (as compared to a healthy person). To qualify for benefits and services, the person should have a degree of permanent disability of at least 50 percent. As noted above, the assessment of permanent disability is based on medical documentation, justifying the degree of impairments in diseased or injured body part or structure, detailed relevant clinical history, in-depth clinical examination, and, in some cases, targeted laboratory and examinations performed by TMEC. OME specifies that the expertise of permanent disability includes: a. an assessment of the need for care assistance from others and terms of such assistance, b. a decision on the duration of permanent disability and dates of its beginning and expiration, c. an opinion on the causal connection between the impairment and related disability in cases of a work accident, occupational disease, and military service-related disability, d. an opinion on the causal link between the injury (death) and the working conditions (work performed) during the accident at work, e. recommendations for further monitoring and rehabilitation, f. contraindicated working conditions (not applicable to persons of retirement age). The Barème instrument and methodology Annex 1 to OME sets out the medical expertise instrument used for disability assessment in Bulgaria. This instrument is said to provide the 'reference points' for assessment and is a standard Barème instrument – that is, an organ system-based listing of diseases, traumas, and associated impairments (called 'functional limitations') that are directly linked to percentages of disability. As a standard Barème instrument, the medical expertise assumes, without evidence, that a disease state, injury, or associated impairment constitutes an assessment of the overall state of disability of the person as a whole. This assumption does not consider the role of the person's environment on the actual experience of the person with the health condition on the person's actual level of disability. In short, the medical expertise equates disability with health condition or impairment, and as such is inconsistent with the understanding of disability found in the WHO's International Classification of Functioning, Disability and Health (ICF). (A Barème instrument is an operationalization of what is usually called the medical model of disability.) The medical expertise is not uniformly based on the WHO's International Classification of Diseases (ICD) format but rather roughly arranged by diseases and injuries of organ systems (and associated 67 impairments), but with two additional categories of 'internal diseases' and a somewhat random collection of diseases called 'surgical': 1. Diseases of the musculoskeletal system: Chronic osteomyelitis, Muscle diseases, Spinal and pelvic injuries, Scheuermann's disease, Tumor diseases of the musculoskeletal system, Aseptic necrosis, Damage to the upper limbs, Damage to the lower limbs. 2. Mental illness: Organic brain mental disorders, Difficult learning, mental limitations, Prolonged psychosis, Affective psychoses with relatively short but frequent, recurrent phases, Neuroses and abnormal personality developments, Alcoholic disease, Addictions, Mental disorders in childhood. 3. Ear, nose, and throat (ENT) diseases: Hearing analyzer, Vestibular disorders, Nasal and throat diseases, Speech impairment due to damage to the vocal cords, Respiratory and vocal disorders due to damage to the larynx and trachea, Malignant neoplasms of the ENT organs. 4. Diseases of the cardiovascular system: Organic heart damage, Cardiac interventions, Rhythm and conduction disorders, Arterial hypertension, Functional cardiovascular syndromes. 5. Eye Diseases: Visual acuity, Peripheral vision, Paralysis, Mydriasis, Disturbed adaptation, Diseases of the appendages of the eye and eye muscles, Lack of eye lens. 6. Lung Diseases: Rib fractures and chest deformities, Bronchiectasis as a separate disease, Pneumoconiosis, Bronchial asthma, Malignant neoplasms of the respiratory system and chest organs, Tuberculosis, Sarcoidosis, Pulmonary thromboembolism, Chronic obstructive pulmonary disease (COPD), Other diseases of the Lungs, Degrees of functional disorders. 7. Diseases of the nervous system. 8. Surgical diseases: vascular diseases of the upper extremities, Diseases of the arteries (stenosis and thrombosis) of the lower extremities, Chronic venous disease, Aneurysms and arteriovenous fistulas, Diseases of the esophagus, Diseases of the gastrointestinal tract, Malignant diseases of the liver, bile ducts and gallbladder, Hernias, Urinary organs, Male genitals, Female genitals. 9. Internal Diseases: Diabetes mellitus, Diseases of the thyroid gland, Diseases of the parathyroid glands, Diseases of the adrenal glands, Pituitary disorders, Hypotrophies and dystrophies in childhood, Rickets, Other metabolic diseases, Adiposities permagna /Obesity, Generalized osteoporosis, Genetic abnormalities, Diseases of the esophagus, Stomach diseases, Intestinal diseases, Liver disease, Diseases of the pancreas, Malignant blood diseases, Other diseases of the blood and blood-forming organs, Kidney and urinary tract diseases, Parasitic diseases, Infectious diseases, Chronic occupational poisoning – according to the list of occupational diseases, Diseases of the musculoskeletal system. 10. Skin Diseases. In the case where the applicant's medical documentation suggests the presence of more than one disease, injury or associated impairments, Annex 2 sets out the methodology explained above. For example, if a person has Perthes' disease in an active stage with resulting 71 percent disability, but also has the loss of one thumb (30 percent disability) and visual acuity under 0.05 of left eye (50 percent). The final disability percentage in this case would be 87%. 3.6. Redress system: Appeals and objections Appeals and objections can be made by persons who have undergone medical examination or their legal representatives, insurers, the NSSI, the Agency for Social Assistance and the Agency for People with Disabilities. Institutions that can rule on appeals are TMECs, NMEC, the regional council or the administrative court. Appeal procedures are described in the Health Act (Art. 122). 68 Figure 3.3: Steps for appealing decision on disability The appeals to the decisions made by GP, attending physician, MAC, TMEC or NMEC must be considered not later than 14 days after the appeal has been filed following the cascading hierarchy below (Figure 3.3 for illustration): • Appeals against decisions of general practitioner or attending physician. The person appeals to MAC, if she/he believes there is an incorrect assessment of her/his disability or when the sick leave is refused. Appeals should be submitted through the regional council. 108 МАC reviews the decision of the GP and either confirms or revokes and corrects it. • Appeals against the decisions of MACs are handled by TMECs. Where “the requirements and procedures for issuing expert decisions for temporary disability are presumably violated” appeals can also be submitted to the regional council, which can confirm the decision or revoke and assign a different MAC for a new decision. • Appeals against the decisions of TMECs are handled by NMEC. The appeals are submitted through RFME. NMEC has an expert council with consultative functions for resolving disputable cases. NMEC does not rule on diseases that have arisen after the issuance of the expert decision. NMEC can confirm the decision or revoke and return the case for a new ruling by TMEC. It can also directly issue a new decision. • Appeals against the decisions of NMEC are handled by the relevant Administrative Court following the Administrative Procedure Code. The court may rule NMEC decision incorrect and send it back for a review; subsequent appeals are sent to the Supreme Court. Every quarter NMEC prepares a plan for inspections of TMECs and their decisions. In 2019, NMEC carried out 1,891 inspections as part of the planned monitoring and 4,449 checks, based on complaints. Other institutions (such as RHI) carried out another 1,373 checks. NMEC also carries out inspections on a random basis of not less than 3 percent of the expert decisions of TMECs that have 108 A regional council is in each Regional Health Inspectorate and includes representatives of the Regional Health Inspection, the Territorial Division of the National Social Security Institute, and the Regional Health Insurance Fund (Art. 111 of the Health Act). 69 not been appealed. As a result of the inspections, NMEC may revoke or amend incorrect decisions of TMECs, as well as return the TMEC decisions for revisions. The head of NMEC may order a review of incorrect or contradictory decisions of its members within three months of their issuance. In 2019, 104 inspections on the organization and quality of the activity of TMEC were carried-out by NMEC and 1,787 inspections were carried-out by the RHIs. The director of the respective RHI establishes a regional council (RC) for the control over the decisions, issued by the bodies for temporary disability. This council includes representatives of the RHI, NSSI and RHIF. The Regional Council also carries out official inspections of not less than 2 percent of the decisions for temporary disability issued on the territory of the respective district based on a random selection. Figure 3.4 shows the annual appeals of TMEC and NMEC expert decisions, based on the annual reports of the Ministry of Health. In 2019, 13,275 TMEC decisions (7.5 percent of all issued expert decisions by TMEC) and 188 NMEC decisions were appealed. For the same year 6,263 of the TMEC decisions and 13 of the NMEC decisions were revoked and had to be revised (or 42,4 percent of the appeals). Figure 3.4: Disability appeals and revoked decisions (2017 -2020) Source: MOH Annual Reports 3.7. Key messages i. Disability assessment (medical expertise) The current disability assessment system is limited by the fact that the Barème medical expertise instrument and methodology used does not assess disability, in the modern sense established by the ICF and enshrined in CRPD. A Barème instrument purports to assess disability as if it was the same thing as a medical condition or impairment, ignoring environmental factors that significantly determine the disability that an individual experiences. The associations between disease and impairment, on the one hand, and 70 percentage of disability on the other are not based on empirical evidence but are conjectural. Barème instruments tend to be scientifically weak and allow for manipulation and biased judgment.109 It is now commonly understood throughout Europe and the world that disability must be assessed as the lived experience of an individual living with one or more health problems – or in ICF terms, as the level of a person's performance in light of his or her intrinsic health capacity and environmental facilitators or barriers. Disability assessment is a 'whole person' or global assessment of the extent or level of a person's disability. As a result, disability assessment should be a summary measure of functioning levels across domains of actions, simple and complex, from walking, taking care of children to working at a job. A summary or global assessment of disability must be based both on the individual health state and on specific assessments of specific activities as performed in the person's actual environment. Yet a summary assessment of disability is valid only if the specific assessments can be statistically summarized into a single assessment score. Bulgaria, like most countries in Europe, has recognized that the concept of 'disability' needs to be understood as a complex phenomenon that results from the interaction of the health problems and impairments people have and their environment. Features of a person's environment can make disability more severe (climatic conditions, building construction, stigma and attitudes) or less severe (assistive technology, modifications to home environments, supportive friends and family). This is the model of disability found in the ICF and the CRPD. Moreover, the Bulgarian Persons with Disabilities Act explicitly defined people with disabilities consistent with the ICF approach: people with disabilities " are persons with physical, mental, intellectual and sensory insufficiency, who in interaction with their environment could hinder their full and effective participation in public life." While countries are taking steps to move away from a purely medical assessment of disability of the sort represented by the Medical Expertise, Bulgaria has yet to take the concrete steps needed to do so, consistent with its own legislation. Test piloting of the WHO’s functioning assessment instrument – Disability Assessment Schedule 2.0 (WHODAS 2.0) conducted within the same project under which this Report was prepared, provides an opportunity for Bulgaria to consider systematic inclusion of functioning into disability assessment based on empirical evidence.110 We therefore recommend: • Revision of the disability assessment system by explicitly including functioning (“performance” in the ICF terms) through a psychometrically valid and reliable measurement of functioning. The change in methodology should be based on empirical evidence. This evidence can be statistically developed into an automated algorithm that would calculate degrees of disability and reduced work capacity in a scientifically sound, non-arbitrary or non- discretionary fashion. • Create specific disability assessment methodologies that are adapted to specific situations of children, the working age population, and retired people. 109 Bickenbach J, Posarac A, Cieza A and Kostanjsek N. 2015. Assessing Disability in Working Age Population – A Paradigm Shift: from Impairment and Functional Limitation to the Disability Approach. Report No: ACS14124. Washington, DC.: The World Bank. 110 The WHODAS 2.0, 36-question version was pilot-tested in Bulgaria on 3,200 applicants for disability assessment in late 2021-early 2022. The statistical analysis of the pilot data confirmed that WHODAS is psychometrically valid and reliable instrument that captures the ICF construct of disability and that including it into disability assessment in Bulgaria would significantly improve the accuracy of disability determination. For more information see: Carolina Fellinghauer, Aleksandra Posarac, Jerome Bickenbach and Marijana Jasarevic. 2022. Options for Improving Comprehensive Functioning and Needs Assessment in Bulgaria. @World Bank. 71 ii. Organization of temporary and permanent disability assessment The assessments of temporary and permanent disability are organized in Bulgaria differently from many other countries. In Bulgaria, organization and conduct of these functions that are important both for affected persons and the state is delegated to medical establishments (mostly hospitals), engaging thousands of medical doctors. As evidenced by high numbers of inspections of MACs and TMECs and appeals, the system is not fully trusted by the public and administration. While the current organization of assessment helps achieve better territorial coverage of services, it is difficult to ensure the absence of conflict of interest (in small towns where everyone knows everyone) or a strict and consistent application of the expertise methodology. The current system incurs increased cost to the national health budget by additional diagnostic procedures normally conducted at the medical institutions where the patient had been treated and is being assessed (which may or may not be needed), as well as increased cost to the Social Security Fund that pays for the sick leave. In addition, the way in which members of MACs and TMECs are paid for their work is not entirely transparent. The outcome is a need for increased layers of checks and rechecks of MACs and TMECs decisions. We thus recommend: • Bulgaria should reconsider the way in which temporary and permanent disability are assessed and consider establishing a specialized government agency to perform these functions, with permanent experts and territorial branches. One option would be to transform NMEC into an executive agency with territorial divisions covering the whole country. It should be noted that in most of the world (EU countries included), disability assessment is not delegated to health facilities but performed by a state designated executive body – be it under the social security administration or ministry of social affairs, or ministry of health. The advantages are many, from cost-efficiency, standardized application of assessment methods, staff capacity development and monitoring and evaluation. While governance concerns and corruption are difficult to be eliminated, there are methods of how to organize assessment that could minimize these risk. For instance, in some countries (e.g., Greece) teams from another cities conduct assessment in other cities, thus minimizing human interaction prior to the assessment, etc. iii. Administrative processes An applicant’s journey through the system of MACs and TMECs appears long. To an outsider looking at the system from the regulatory documents, it appears that there is an endless demand for medical documents, additional diagnostic procedures, multiple applications, and multiple commissions. The decisions take long time (e.g., a MAC may take three months to issue a decision). We thus recommend: • MOH, NHIF, NMEC, NSSI, and other key stakeholders should come together and map all administrative processes by types of assessment with the objective of making the client journey through the system easier, shorter and less time consuming. • Referrals to MACs and TMECs should exclusively be channeled electronically through the regional health files. • Implement a one-stop shop approach. The flow of documents should be electronic and automated, and applicants should not be asked to provide medical or other documentation unless the documents are missing. Even in such situations, the documents should be obtained 72 by institutions through official exchange of information (this should not be complicated in an integrated information system). • All assessments should include a face-to-face interview, as an essential part of collecting information for disability assessment. • Introduce a rule that a patient seeking MAC or TMEC decision should be assessed only by a MAC or TMEC operated by a different medical institution from the one where she/he was treated. The referrals to a concrete MAC, TMEC or NMEC should be done by the regional health files to insure the application of this principle. Ideally, RHF would also schedule appointments with MACs or TMECs. Note: for the presentation and discussion of issues pertaining to a management information system related to medical expertise, see Chapter 7 of this Report. 3.8. Annex 1: Institutional framework The following table summarizes the responsibilities of each institution or individual in the process of disability assessment, decision, management, and control. Institution Responsibilities National Council of • provides methodological and consultative guidance and assistance and Medical Expertise control over the organization and quality of medical expertise commissions • participates in the inspections of medical institutions (organization of work, quality of ME, documentation, etc.) • organizes and conducts training for building competences of doctors in TMECs. Regional Council of • controls medical expertise for temporary disability and provides Medical Expertise methodological support (consists of experts from • inspects organization of work, quality of medical expertise, keeping of RHI, territorial unit of NSSI medical documentation and the composition of MACs. Carries out official and NHIF) random inspections of not less than 2% of the decisions for temporary work incapacity issued by MACs on the territory under its jurisdiction • organizes and conducts events for increasing expertise of doctors from the region in the field of medical expertise • performs administrative audit of the documentation for the medical expertise assessment. Minister of Health (MOH) • approves the templates of medical protocols and expert decisions of MAC, TMEC and NMEC • gives instructions on the application of the Regulation for the medical expertise to TMEC • approves TMECs to be established • assigns and confirms the Director of NMEC. National Social Security • conducts working conditions investigation that has led to professional Institute (NSSI) illness or work accident of the person, requesting expert decision for permanent disability • has controlling function through the medical commissions of its territorial departments, which perform control over all expert decisions that that result in permanent disability of 50% and over that lead to disability pension. 73 Regional Health • organize and manage the medical expertise Inspectorate (RHIs) • order and confirms the establishment of MACs and TMECs • approve the members of MACs (both permanent and reserve) on the proposal of the respective heads of the medical institutions • maintain database with up-to-date information of general and specialized MACs, and TMECS. Regional files for ME at • collect and archive applications, the Е213 forms and all related medical the RHIs documentation • Register, process and maintain the health information for the persons with expert decisions for permanent disability by TMEC and NMEC. National Health Insurance • Pays for the medical expertise of insured people. Fund (NHIF) National Expert Medical • participates in the development of draft strategies and programs in the Commission (NMEC) field of national health policy and regulations related to the medical expertise • participates in the development of the legislation on medical expertise • performs initial and yearly trainings of the doctors in TMECs • maintains database of trained doctors • maintains database of all persons who have passed through TMEC or NMEC for medical expertise on permanent disability • examines and rules on the appealed decisions of TMECs based on the medical documentation at the moment of enactment of the appealed decision • provides methodological assistance and control over the organization and quality of the expertise activity of TMECs • the Director of NMEC may order a review of an incomplete, incorrect, or contradictory decision of TMEC or NMEC within three months of their making. Territorial Expert Medical • determine the composition of TMECs (1 week after receiving order from Commissions (TMEC) at the RHI) State and Municipal • perform medical expertise for temporary disability (over 6 months) medical institutions • perform medical expertise and decision for permanent disability of children up to 16 years of age • perform the ME and decision for permanent disability and reduced work capacity for persons of working age (insured or not) and of retired persons • determines and confirms occupational nature of disability • suggests work adaptation for employed persons with permanent reduced work capacity at or over 50 %. Medical Assessment • performs medical expertise for temporary disability (or capacity for work) Commissions (MAC) in • suggests work adaptation for employed persons with temporary incapacity Medical Institutions for work and for reduced work capacity (under 50%) • fills-in online and store the data of the sick leaves at their issuance or cancellation. • performs medical expertise for temporary disability (or capacity for work) General Practitioner or Appointed Doctor or • suggests work adaptation for employed persons with temporary incapacity Dentist for work and reduced work capacity (under 50%) • enter and stores data on sick leaves at their issuance or cancellation. 74 Chapter 4: Complex individual needs assessment of persons with disabilities in Bulgaria This Chapter describes Bulgaria's individual needs assessment (INA) process and administrative procedures, in the context of the provision of benefits and services following disability assessment and certification (described in Chapter 3). In the context of health and social welfare programming for persons with disabilities, an INA is a tool that identifies what a person requires in terms of supports and services in response to needs that are created by problems in functioning that result from an underlying health problem – disease, injury or other condition that results in one or more impairments of body functions or structures.111 CRPD mandates that persons with disabilities have the right to the provision of health and social services "based on the multidisciplinary assessment of individual needs and strengths". 4.1. Development of complex individual needs assessment in Bulgaria INA was first suggested in Bulgaria in 2005 in the Integration of Persons with Disabilities Act (IPDA), where it is described as a 'social assessment' establishing rehabilitation, training opportunities, and social service needs and carried out "with the medical expertise of disability”.112 It was not until the Persons with Disabilities Act (PDA)113 and the Regulation on the Implementation of Persons with Disabilities Act (PDA Regulation),114 in 2019 that a more complete INA was described and its procedures established. Article 20 of PDA created the legal right of persons with disabilities to a complex and individual assessment of needs that examines "the functioning difficulties of a person with a disability, related to her/his health condition and the presence of barriers in the performance of daily and other activities, as well as the type of support needed." This statement reflects the concepts of functioning and disability found in the World Health Organization's International Classification of Functioning, Disability and Health (ICF), and as well the CRPD's characterization of 'persons with disabilities'. There is, however, no further mention of the ICF in either PDA or its Regulation. At the same time, the methodology for conducting the INA was developed as an intergovernmental project prepared by a team of experts from the Disability Policy, Equal Opportunities and Social Assistance Directorate, and assisted by experts from the Social Assistance Agency and parents of children with disabilities. This was supported by a project (2010-2012) funded by the government of Netherlands under the MATRA Pre-Accession Program (MPAP) program.115 Following the Dutch individual needs assessment, and their adherence to ICF and its model of functioning, a questionnaire was developed to be filled in by a case manager who would collect information from the person. In general, following the Dutch experience and practice, INA was to be, at least in principle, based on a self-assessment checked and validated by experts. The Dutch project also concluded that support be provided to people completing the self-assessment form, that there be anonymity in conducting the 112 Article 12, Integration of Persons with Disabilities Act. https://www.lex.bg/laws/ldoc/2135491478 113 Articles 20-27, PDA. Ibid. 114 Articles 14-20, Regulation on the Implementation of the Persons with Disabilities Act. https://www.lex.bg/bg/laws/ldoc/2137192229. 115 “From planning to effective provision of community based social services to persons with intellectual disabilities in Bulgaria” MAT09/BG/9/1, funded by the Dutch Ministry of Foreign Affairs under the MATRA Pre Accession Program (MPAP). 75 evaluation to avoid bias, and that the process be monitored over time to improve the methodology. These recommendations, however, were not implemented. The link between INA and the ICF is most clearly made in Article 1 of the Methodology for Conducting an Individual Assessment of the Needs for Support to Persons with Disabilities (The Needs Assessment Methodology - NAM):116 Art. 1. (1) The methodology shall regulate the way in which to prepare an individual assessment of the needs of persons with disabilities within the meaning of the Article 20, para 1 of the Persons with Disabilities Act, including the assessment of the need for the provision of social services, personal assistance, or other support under conditions and by order laid out by law. (2) This methodology is based on the bio-psycho-social model of disability, taking into account the International Classification of Functioning, Disability and Health of the World Health Organization (ICF). (3) The methodology regards disability as a general consequence of problems in functioning of a person with a disability, which is an umbrella concept covering all functions and structures of the body, activities, and opportunities for social inclusion. (4) The model under para. 2 shall consider: 1. functioning of the person with a disability - for the performance of an action the person with a disability must have the appropriate functionality of the body, including physical, mental, intellectual, and sensory functionality that allows its full participation in public life, 2. possibilities - the environment does not prevent the person with a disability from fulfilling its functionality through the relevant actions, 3. will - the person with a disability should be willing to perform specific actions (unless insufficient desire is an expression of illness or functional damage). (5) The purpose of the individual assessment under Art. 20, para 1 of the Persons with Disabilities Act is to obtain detailed information about the situation regarding the participation of the person with a disability in society and to establish the individual needs for support. (6) This methodology, in accordance with the ICF, covers the following nine areas of life: 1. training and application of knowledge, 2. common tasks and requirements, 3. communication, 4. mobility, 5. self-care, 6. home life, 7. interpersonal interactions and relationships, 8. main areas of everyday life, 9. civic and public life. 116 The Methodology for Conducting an Individual Assessment of the Needs for Support to Persons with Disabilities. Effective from April 1, 2019. Adopted by Council of Ministers № 64 dated March 29, 2019. Prom. DV. no. 27 from April 2, 2019; ext. DV. no. 33 from April 7, 2020; ext. DV. no. 48 from May 26, 2020, amended DV. no. 58 from July 13, 2021. https://www.lex.bg/bg/laws/ldoc/2137192215/. 76 Other Bulgarian legislation mentions INA with respect to specific benefits: Article 12 of the Personal Assistance Act (PAA) states that an INA and decision of the Social Assistance Agency (SAA) under the Article 25 of PDA is required for state-financed personal assistance.117 It should be noted that this assessment of needs is different from a needs assessment regulated by the Social Services Act118 (SSA), which is conducted as part of the development of an individual support plan119 that is the primary precondition for the provision of all services for vulnerable and at risk persons, including persons with disabilities. Article 6 of SSA describes this particular (social work and services specific) individual needs assessment (SSA INA) as: (1) The individual needs assessment shall be a professional study of the life situation and the psycho-social conditions of the person, to determine her/his emotional and social needs as well as needs for development and participation, to guide the social work. (2) The assessment shall include professional opinions, conclusions and recommendations based on analysis. While the language may be different, the two individual needs assessments talk about very similar issues. Going forward, efforts should be made to harmonize the two and to collect as much relevant information as needed in the PDA INA, with the SSA INA focusing on the content of the social service, e.g., the content of the psycho-social counselling, etc. 4.2. Individual needs assessment in the Persons with Disabilities Act (PDA INA) As noted, Article 1 of the NAM offers the closest links between the INA and the ICF. However, the characterization of the ICF 'bio-psycho-social model is somewhat confused. For although disability is described as a problem in functioning (or 'functionality' as it is termed), functionality itself is characterized as a capacity of the body not, as in ICF, the outcome of an interaction between the capacity of the body and environmental factors. Moreover, unlike the ICF, the environment – called 'possibilities' – is described as preventing "the person with a disability from fulfilling its functionality through relevant actions," rather than, as in the ICF, creating the level of functioning in the person's performance of activities. As these differences are fundamental, it is not accurate to say that the current PDA INA described in NAM is consistent with the ICF. Main principles of the PDA INA Although not aligned with the ICF, PDA INA described in NAM is consistent with recognized international practice in as much as NAM in Article 1 defines eight essential properties of a comprehensive individual needs assessment:120 1. Transparency and objectivity – inclusion and active participation of the person with a disability throughout the process, and in particular the use of understandable and transparent tools; for the purposes of monitoring the results, a review of the results is necessary. 2. Inter- institutional collaboration of relevant institutions. The needs of the person with a disability and the support measures must be fully defined by providing for a common social inclusion plan in society, in accordance with the provisions of PDA. 117 The Personal Assistance Act. https://www.lex.bg/bg/laws/ldoc/2137189250. 118 The Social Services Act. https://www.lex.bg/bg/laws/ldoc/2137191914 119 See Article 28 of the Regulation on the Implementation of the Social Service Act. https://www.lex.bg/bg/laws/ldoc/2137207105. 120 NAM, Article 1, paragraph 6. Ibid. It should be noted that these principles are from PDA, and they apply to all of its provisions, including the individual needs assessment. 77 3. Interdisciplinarity – depending on the specific case, other relevant specialists or experts may be invited to participate in the needs assessment. 4. Acceptance orientation – the determination of support measures to be achieved by mutual agreement; this requires the involvement of a person with a disability in the process by ensuring clarity and transparency and considering her/his wishes and objectives. 5. Individual approach – all steps within the process in the preparation of the PDA INA must be adapted to the needs of the person with a disability. 6. Personal orientation – to ensure the principle of personal orientation, the life of a person with a disability, the specific circumstances of life, as well as his experience must be known; all these should be considered in the definition of needs and in the specific planning of the necessary support measures, as well as disruptions in functioning and the resulting restrictions in social inclusion. 7. External factors – considering environmental factors in determining needs; this also applies to the provision of specific support measures, and to documenting relevant factors and barriers. 8. Purposefulness – ensuring adequate support for the person with a disability. These principles will be useful when we consider below whether the actual practice of the PDA INA in Bulgaria satisfies the right that persons with disabilities have to a complex INA for financial support, service, and other public benefits. 4.3. Assessment information and forms Article 2 of NAM describes 3 components of INA (the template for the assessment is provided in the Annex 1 to NAM; see also Annex 5 to this Report). Component I: information about the person with a disability in connection with social, family, household and health circumstances and others related to her/his difficulties and the possibility for her/his social inclusion, indicated in the self-assessment form. Component II: objective findings of the social worker regarding the person's status of health and functioning difficulties and barriers she or he experiences in the performance of daily and other activities. The information in components I and II is filled in by an SAA social worker leading the case. Component III: conclusions related to specific targeted support measures in accordance with the stated and established individual needs of the person with a disability; the conclusions may include financial support under the Persons with Disability Act; the need to use social services under conditions and in accordance with the procedure established by law; the need to provide a certain number of hours of personal assistance under conditions and in the manner prescribed by law, or the need to provide other types of support under conditions and in the manner prescribed by law. The information in Component III is filled in by a specialized unit within the SAA at the municipal level called the Social Assistance Directorate (SAD) The 'self-assessment form' referred to in the Component I is an extensive template (Article 21(3)(2)121 of PDA) (see Annex 5 to this Report) as one of three essential documents used for the preparation of 121 A self-assessment template is approved by the Executive Director of the SAA. 78 INA (the other two are the application-declaration form122 and the medical expertise decision by TMEC or NMEC). Each of these three forms is described more fully below: • Individual Needs Assessment Report The INA Report (see Annex 5 to this Report) is a two-page document summarizing information from components I and II, both of which are provided by a social worker assigned to lead the case. Component I, beside basic personal details, contains a "self-assessment of the difficulties in the home environment and outside of it". This suggests that the responsible social worker is required to summarize information about the home and outside environment from the Self-Assessment Form. But the Self-Assessment Form does not ask questions about the person's environment; instead, it asks questions about difficulties in performing actions in seven domains with the “yes”/”no” answer format. It is not clear how this part of the template is to be completed, except to list “yes” and “no” answers. In Component II of this report, the social worker provides the medical expertise from TEMC or NEMC, and summarizes information from the Social Worker Form: i. type of difficulty in functioning, ii. degree of difficulty, iii. degree of inclusion in the social environment, iv. mobility in the social environment and difficulties outside home, v. need for the provision of a specific type of support, and vi. other functioning difficulties and barriers in everyday life from the self-assessment form or findings during the assessment. Component III contains conclusions with respect to needed supportive measures. • Social Worker Form123 This extensive ten-part form is the core of the INA and is filled in by a social worker to whom the case is assigned. The form contains the following parts: Personal information (Part 1); Medical expertise findings (Part 2); Part 3: information about "functional insufficiency/health condition" in terms of intellectual, physical, mental, and sensory 'insufficiencies' based on findings and opinions of medical specialists. Part 3 is difficult to understand. If it is merely medical diagnosis, then this information is already contained, in full, in the MAC/TMEC/NMEC documents. But if Part 3 is supposed to contain other information, it is not clear what the source is, or what 'insufficiencies' are. Parts 4 and 5 are to be completed only if personal assistance is recommended by TMEC/NMEC and subsequently requested, as the issues raised in these parts deal with "conditions and skills required to establish autonomy". These are the only parts of this form that require the social worker to make personal contact with the person and visit him or her at home to identify the person’s difficulties and needs and conduct an interview with the person, or a representative. Part 4 asks questions about problems a person has in motor, self-care, orientation and self-protection, and psycho-social functions 122 The application/declaration form is approved by the Executive Director of SAA. 123 This form was based on the form suggested by the Dutch consultancy project MPAP. This explains the somewhat peculiar distinction between Part 4 "Information on the existing problems with the functioning of the persons with disability" and Part 5 "Information on the impact of constraints on the life of the person with a disability" seemingly reflecting a presumed distinction between ICF activities and ICF participation (a distinction which is not made in the ICF itself). 79 and Part 5 asks about the 'impact of constraints' on the person's life in social functioning, activities in the home environment, and social relationships. (Items pertaining to self-care and some items pertaining to social functioning are not applicable to children under 18; additionally, activities in the home environment are not applicable to children under 12). For each of the 35 issues listed, difficulty or dependency is assessed on a 5-point scale: • 4 = there is a problem: degree of total dependency/difficulties • 3 = there is a problem: degree of very grave dependency/difficulties • 2 = there is a problem: degree of grave dependency/difficulties • 1 = there is a problem: degree of moderate dependency/difficulties • 0 = there is no problem/there is no need of support PDA further defines these categories as follows: • Point 4 - Total dependency/difficulties: the need for constant support by another person to carry out various activities in daily life more than four times a day due to total loss of physical, mental, intellectual, or sensory autonomy. • Point 3 - Very grave dependency/difficulties: the need for assistance to carry out various activities in daily life no more than four times a day or a need for limited support for personal autonomy. • Point 2 - Grave dependency/difficulties: the need for assistance to carry out various activities in daily life up to two times a day or a need for limited support for personal autonomy. • Point 1 - Moderate dependency/difficulties: the need to carry out various activities in daily life several times a month or a need for limited support for personal autonomy At the end of each of the seven functioning or impact sections in Parts 4 and 5 a 'Total score' box is provided for the sum of the scores in each section. However, only the total scores for sections 4.1 - 4.4 and 5.1 – 5.3 are used, and they are used only in Part 7 to determine the number of hours of personal assistance the person is assessed to need. Part 6 collects information on participation in education and labor market. Parts 7-9 collect information on existing family support and need for personal assistance, need for home adaptation, municipal housing, assistive or medical aids, private motor vehicle, rehabilitation services, and monthly financial support. Finally, Part 10 asks for the wishes of the person for services and supports, their duration, and motivations for social integration. • Self-assessment form The self-assessment form124 for the most part mirrors the Social Worker Form: i. Personal information ii. TMEC/NMEC determined percentage of reduced work capacity or type and degree of disability (and questions about presence of intellectual, physical, mental, or sensory 'insufficiency') iii. Summary of services/supports requested (including personal assistance) iv. Functioning questionnaire: I. Motor functioning; II. Self-care; III Orientation and self- protection; IV Psycho-social functions; V. Social functioning; VI. Activities in the home 124 Described as “Form No 2 under Article 21(3)(2) PDA approved by the Order No RD01-0727 of 29 March 2019 of the SAA Executive Director”. It is available at: https://asp.government.bg/bg/deynosti/sotsialno- podpomagane/podkrepa-na-horata-s-uvrezhdaniya/individualna-otsenka-na-potrebnostite. 80 environment; VII Social relationships. After each set of questions, the applicant is asked for a "description of the nature of the problems". (V-VII are only required if the applicant is asking for personal assistance.) v. Detailed requests for specific supports and services (educational, employment, social services, balneological treatment and rehabilitation services, targeted financial support for private vehicle, adaptation of home, municipal housing rent, and auxiliary aids and medical devices support, or monthly financial support). Although the Social Worker and the Self-Assessment forms mirror each other, they are also very different in how they collect information about functioning. While the Social Worker Form uses standard dependency questions from rehabilitation therapy instruments, with a five-point scale,125 the Self-Assessment Form presents the questions in a very simple and direct format and requires only a “yes” or “no” response. This can be seen in Tables 4.1 and 4.2: Table 4.1: An extract from the Social Worker Form 5.3. Social Relationships 5.3. Problems of the person with a disability in social relationships Problems: 5.3.1. Establish and maintain contacts with other people on her/his own in the home environment, in a familiar closed environment or an unfamiliar closed environment outside the home. 0 1 2 3 4 Specify on each line whether a problem is established and what the degree of dependence/difficulty is (1, 2, 3, 4), depending on the age and the age-related conditions and skills. 5.3.2. Participate on her/his own in activities together with other people, initiate participation, take interest in participating, and have the opportunity to participate 0 1 2 3 4 Check “0” if no problem exists. 125 But only for personal assistance, not for other benefits and services. 81 Table 4.2: An extract from the Self -Assessment Form VII. Social relationships How do you manage: Please circle each correct answer To establish and maintain • I establish and maintain social contacts on my own yes no social contacts • I establish and maintain social contacts in an unfamiliar closed environment outside home yes no • I establish and maintain social contacts in a familiar closed environment outside home yes no • I establish and maintain social contacts in my home environment yes no To participate in activities • I participate in various activities with other people on yes no together with other my own people • I take the initiative to participate in activities with other yes no people • I am interested in participating in activities with other yes no people • I have the opportunity to participate in activities with yes no other people Explanation of the nature of problems: 4.4. Domains of support Chapter 4 of PDA identifies domains of support for persons with disabilities and details the corresponding means of support: Article 5. (1) The domains of support for persons with disabilities shall be as follows: 1. health 2. education 3. employment 4. housing 5. accessible environment in urban areas and public buildings 6. transport 7. culture 8. sports 9. private life 10. social and political life 11. justice 12. others. (2) The means of supporting persons with disabilities with a view toward their social inclusion shall be, among others: 1. medical, professional, social, occupational, and psychological rehabilitation, 2. education and vocational training, 3. employability services, 4. accessibility and reasonable accommodations, 82 5. social services, 6. financial support, 7. accessible information, 8. access to justice and legal protection, 9. provision of personal mobility ensuring a maximum degree of independence, 10. personal assistance, 11. universal design, 12. others. Not all these support measures and benefits require an individual needs assessment; those that do are specified in PDA and accordingly included in NAM. Article 4: Financial support for the provision of technical aids. Article 5: Financial support for the purchase of a private motor vehicle. Article 6: Financial support for housing adjustment. Article 7: Financial support for balneotherapy and/or rehabilitation services. Article 8: Financial support for the rental of municipal dwelling. Article 9: Monthly financial support. Articles 10, 11: Personal assistance. Article 12: Relevant social service/type of activity. Article 13: Other support. Each of these services and benefits have their specific eligibility requirements and procedures (see Chapter 5 and Annex 4 to this Report) and in each case the Self-Assessment Form must explicitly state the relevant need. However, looking at the instruments used for the assessment, except for sections 4 and 5 to determine the level of dependency and number of hours of personal assistance (see Annex 5 to this Report), other sections mostly look like an initial screening for benefits eligibility, not an assessment of functioning and needs to improve it. The methodology for determining the personal assistance need is the most detailed (only adults with a disability percentage 90 or over, or a child with disability percentage of 50 or more are eligible). The determination of the number of hours of personal assistance is based on the degree of dependency/difficulty and by age group (18 years and over, 12-18 years, and under 12 years). In Part 7 of the social workers form, a total score is calculated as the sum of the scores under the designated sections of Parts 4 and 5 (4.1 - 4.4 and 5.1 – 5.3). This score is then multiplied by 1.234 for people 18 years and above, by 1.313 for those between 12 and 18, and by 1.556 for children under 12. The result, once rounded up, is the maximum number of hours of personal assistance per month. It is not clear how these coefficients have been determined and why they are applied. 4.5. Individual needs assessment administrative process The assessment is conducted by a specialized municipal unit of SAA called the Social Assistance Directorate (SAD).126 The primary functions of the SAD are to conduct INA and provide benefits and supports to persons with disabilities as approved by the needs assessment process. SAD is also responsible for providing information and relevant documents (from SAD office or on SAA website) to persons requesting individual needs assessment.127 All activities of the SAD are managed and supported methodologically by the SAA Regional Directorates, which are organized on the regional basis, according to the administrative division in the country. Methodological support is only provided if requested on a specific case. As noted, the overall process of INA is regulated by the Regulation on 126 Article 21 of the Persons with Disabilities Act. Ibid. 127 Article 6 of the Social Protection Act. https://lex.bg/laws/ldoc/2134405633/ 83 the Implementation of Persons with Disabilities Act (Regulation PDA).128 Figure 4.1 presents the key INA administrative steps. Figure 4.1: PDA Individual Needs Assessment administrative process flow chart 1. 2. 3. Application to SAD for Case registration and Case assessment, home an individual needs appointment of a visit and filling of the assessment responsible social social worker form worker 4. 6. 5. Preparation of and INA Issuance of an order or SAD decision Report a direction meeting The PDA distinguishes between INA for personal assistance services and needs assessment for other available supports and benefits. If the applicant requests personal assistance services, then Parts 4 and 5 of the Case Manager Form need to be completed, and sections V-VII of the functioning part of the Self-Assessment Form are required; for other benefits and services these are not required. The process for other benefits and services is, as noted, only checking if a person meets eligibility requirements. The needs are assessed only for personal assistance where methodology is more complex as a level of dependency is determined and the number of hours of assistance computed. The INA process is based on the services/benefits that are requested and thus assumes that a person knows which services she/he needs (the person must list the services she/he needs in the application and the self-assessment form). This may not necessarily be correct. Moreover, it is not consistent with the purpose of the needs assessment – to assess the state of functioning of a person with a disability in her/his environment and determine needs for interventions that would improve functioning (and are provided in Bulgaria). While a person may list the services that she/he believes she/he needs and wishes to benefit from, it is the needs assessment that should determine the needs. (Note that persons with disabilities are eligible to receive some benefits irrespective of the needs assessment – see Chapter 5 and Annex 4 to this Report.) Application to SAD for INA Once a person has received from TMEC/NMEC a disability certificate (see Chapter 3), to receive benefits, services and personal assistance, she/he must apply for an INA by submitting to a SAD office the following: i) an application requesting an individual needs assessment, specifying requested benefits, ii) a completed Self-Assessment Form, iii) her/his identity card, iv) a copy of the TMEC or NMEC decision, and 128 Articles 14-20. Regulation on Implementation of the Persons with Disabilities Act. https://www.lex.bg/bg/laws/ldoc/2137192229/. 84 v) copies of medical documents, including the documents required for the eligibility criteria (listed in the relevant legislation) for each requested benefit. Both children and adults submit the same documents, although the Self-Assessment Form identifies areas of information not required for children. The documents can be submitted in person on paper (by a person or her/his legal representative), by a post mail or courier, or electronically with qualified electronic signature. The INA process can also be initiated by a child's parent, guardian, foster or adoptive parent or by a director of the residential service where the child or adult resides. A Head of a SAD office can also initiate the process. Case registration and assignment of a social worker The relevant SAD office registers the application electronically and issues the application number. The head of the SAD assigns a social worker to handle the case. Case review, home visit and filling of the Social Worker Form The assigned social worker reviews submitted documents and if some documents are missing, he or she may request them from the applicant within 14 days from the application. The social worker may also require documents or data from public agencies if required to complete the Social Worker Form (e.g., tax administration or access to labor contracts data base). If the benefit requested is personal assistance or a living space adaptation, the case manager will conduct a home visit and may interview the person with respect to the questions in the Self-Assessment Form. When personal assistance is requested, and the entire Self-Assessment and Social Worker Forms are used, then the primary purpose of the home visit and interview are to determine the level of dependance and the number of hours of personal assistance to be provided as regulated by PAA.129 It should be remembered that is the TMECs/NMEC that decide that a person with disability of at least 90 percent needs personal assistance (“assistance from others”). The needs assessment only serves to determine the level of assistance. Preparation of the INA Report The responsible social worker completes the Social Worker’s Form based on the findings from the Self- Assessment Form and the home visit and interview. As mentioned, only when personal assistance is requested, the sections V-VII of the functioning part of the Self-Assessment Form, and Parts 4 and 5 of the Social Worker’s Form are completed. Nonetheless, sufficient information to support the need for personal assistance and other requested benefits and services (purchase of a personal vehicle, living space adaptation, rehabilitation and balneotherapy services and targeted support for assistive technology, devices, facilities, and medical equipment) must be collected. It is not clear whether and when supporting documentation for these benefits is formally required, but it is a practice of SAD (SAA) to request applicants to present all required documentation together with the application to save time. The social worker also drafts the third section of the INA Form, "Conclusions with findings and proposed support measures”. 129 The four level of dependency according to the last amendments to PAA and implemented from the 1st of January 2021 are: First degree of dependence support – up to 15 hours of monthly personal assistance; Second degree of dependence support – up to 42 hours of monthly personal assistance; Third degree of dependence support – up to 84 hours of monthly personal assistance; Fourth degree of dependence support – up to 168 hours of monthly personal assistance (see also next Chapter on benefits and Annex 4 to this Report). 85 SAD decision meeting The head of the SAD unit and social workers who are handling the cases meet at least once a month to discuss all submitted applications and drafts of INA reports prepared by social workers. Other specialists or experts may be invited to participate. After a discussion, the unit prepares the third section of the Report "Conclusions with specific supportive measures". Decisions with respect to supportive measures are discussed and approved, rejected, or revised based on the opinion of the meeting participants. The applicant, a representative, guardian, or parent of the applicant may attend the meeting (at least a three-day notice of the meeting should be given). The INA Report, with completed conclusions regarding individual support measures is issued in two copies, one of which is handed over to the applicant or her/his representative. Issuance of an Order or a Direction After the INA has been completed, the administrative forms required for the provision of requested benefits are issued. The formal document is issued by a head of SAD within 10 days from the issuance of the conclusions from the individual needs assessment, or the presentation of remaining requested documents. This formal document may either be an order (to SAA to process a particular benefit) or a direction (a referral to other agencies). An order for issuing financial support is applicable for the benefits listed under PDA and provided by SAA. A direction is applicable for personal assistance under PAA, for social services under SAA (only available as of 2022) and for 'other type of support' under PDA. Both orders and directions are given on paper to the person together with the INA conclusion. The person needs these documents when approaching the municipality responsible for provision of personal assistance or social service provider. There is no regulation about sending the document to the responsible institution without the involvement of the person. The person must receive this document personally and then submit it to the relevant institution on his or her own. This is something that can be changed by the introduction of automatic referrals and electronic transmission of documents. PDA states that the validity of the INA is linked to the duration of TMEC/NMEC decision. For persons with TMEC/NMEC decisions for life, a duration of the INA is five years. A new INA can be issued within that time if there is a TMEC/NMEC decision or if there is a change in the person's needs and requested supports. Grievance redress system The INA grievance redress system has two steps. In the first instance, a person who has undergone the INA may submit a grievance either to the head of SAD or to the executive director of SAA. This grievance will be reviewed either by SAA or SAD and it may be rejected, or directions given to SAD to reassess the case. Within a month after having received the appeal, either SAA or SAD will send a letter to the person informing him/her whether the appeal has been approved or rejected. If not satisfied, the person may submit an official complaint to the Administrative Court.130 The Court will only consider complaints related to the procedure of the individual needs assessment. If the Court finds that regulatory requirements had not been followed, it may declare the needs assessment null and void; otherwise, the Court will reject the complaint. 130 Article 24, paragraph 5. Ibid. 86 4.6. Data on individual needs assessments The implementation of the PDA INA commenced in 2019. Table 4.3 presents data on applicants for the INA and approved applications in a 14.5-month period from April 1, 2019, to June 16, 2020. Table 4.3 : Applicants and approved applications for PDA INA by the type of requested benefit Number of applicants No of issued referrals April 1,2019-June 14, 2020)131 Personal Assistance 35,275 33,976 Other benefits under PDA 348,686 n/a January 1-December 31, 2020132 Personal Assistance n/a 24,137 Other benefits under PDA n/a n/a As expected, given eligibility requirements (>90% degree of disability in adults, >50 percent in children), the number of applicants for personal assistance was significantly lower. Personal assistance is a newly introduced measure, and one may expect that most of the eligible persons with disabilities would apply. In total, about half of all persons with disabilities went through an INA in the referenced period. This is not unexpected as eligibility for benefits overlaps with the validity of disability certificate (in most cases one to three years), and, hence, gradually all persons with disabilities will have undergone through an individual needs assessment in the next couple of years. One can, thus, expect that the number of applicants gradually tapers off and stabilizes at about the annual number of certifications and recertifications (about 160,000 per year, or about one case per day per SAD social worker). Overall, in the 14.5-month period from April 1, 2019, to June 16, 2020, the monthly average of applicants was 26,300 persons or 38 per social worker, or 177 per month per SAD. While the number of social workers and the workload varies per SAD, the average number of cases does not seem high (1.7 cases per day and assuming an average of 22 working days in a month). Given the projected tapering off, SADs should be able to comfortably handle the workload. Tables 4.4 and 4.5 present district distribution of persons 18 years of age or older with a degree of TMEC/NMEC determined disability of 90% or higher and the TMEC/NMEC decision that they need assistance by others, who have undergone an INA for personal assistance. 131 The data is from an analysis on the implementation on personal assistance by MLSP, presented to the Working group on PAA on 15.06.2020. 132 https://asp.government.bg/bg/za-agentsiyata/misiya-i-tseli/otcheti-i-dokladi; file:///C:/Users/Vartotojas/Downloads/5679-Godishen-doklad-2020.pdf 87 Table 4.4: Approved adult (18 and older) users of personal assistance, by age groups and districts compared with district population up to 29.02.2020 133 Approved adult users of personal assistance by age groups (90% or more of disability) Districts with total district population Total per 18 - 29 30 - 45 46 - 55 56 - 65 65+ Total 1,000 population Blagoevgrad – 302,694 121 200 156 222 531 1,230 4.1 Burgas – 409,265 103 141 83 164 392 883 2.2 Varna- 469,885 97 123 89 112 424 845 1.8 Veliko Turnovo- 232,568 44 77 53 114 395 683 2.9 Vidin -82,835 20 35 53 77 384 569 6.9 Vratsa – 159,470 46 82 65 127 740 1,060 6.7 Gabrovo – 106,598 18 44 29 48 287 426 4.0 Dobrich – 171,809 38 66 50 67 173 394 2.3 Kardzali – 158,204 52 125 79 115 272 643 4.1 Kyustendil – 116,915 39 51 49 101 457 697 6.0 Lovech – 122,546 34 63 50 80 410 637 5.0 Montana – 127,001 24 51 41 63 369 548 4.3 Pazardjik – 252,776 45 117 80 132 392 766 3.0 Pernik – 119,190 25 46 65 66 358 560 4.7 Pleven – 236,305 165 325 233 284 1,670 2,677 11.3 Plovdiv – 666,801 162 235 143 294 1,177 2,011 3.0 Razgrad – 110,789 49 82 35 93 246 505 4.5 Ruse – 215,477 69 101 74 92 292 628 2.9 Silistra – 108,018 36 66 60 102 386 650 6.0 Sliven – 184,119 41 59 34 52 179 365 2.0 Smolyan – 103,532 45 100 73 105 305 628 6.1 Sofia - capital – 1,328,790 123 225 150 213 912 1,623 1.3 Sofia District – 226,671 70 119 83 122 629 1,023 4.5 Stara Zagora – 313,396 73 109 50 82 364 678 2.2 Targovishte – 110,914 32 51 44 88 199 414 3.8 Haskovo – 225,317 55 104 53 103 280 595 2.6 Shumen – 172,262 48 115 74 145 502 884 5.1 Yambol – 117,335 27 45 21 41 211 345 2.9 Total by age groups 1,701 2,957 2,069 3,304 12,936 22,967 3.33 Source: Social Assistance Agency. 133 The numbers presented in tables in this chapter differ, reflecting availability of data and the period the data cover. 88 Table 4.5: Approved adult (18 years of age and older) users of personal assistance, by age groups and districts compared with district population up to 29.02.2020, shares in % of total Districts with total district 18 - 29 30 - 45 46 - 55 56 - 65 65+ Total population Blagoevgrad – 302,694 9.8 16.3 12.7 18.0 43.2 100.0 Burgas – 409,265 11.7 16.0 9.4 18.6 44.4 100.0 Varna- 469,885 11.5 14.6 10.5 13.3 50.2 100.0 Veliko Turnovo- 232,568 6.4 11.3 7.8 16.7 57.8 100.0 Vidin -82,835 3.5 6.2 9.3 13.5 67.5 100.0 Vratsa – 159,470 4.3 7.7 6.1 12.0 69.8 100.0 Gabrovo – 106,598 4.2 10.3 6.8 11.3 67.4 100.0 Dobrich – 171,809 9.6 16.8 12.7 17.0 43.9 100.0 Kardzali – 158,204 8.1 19.4 12.3 17.9 42.3 100.0 Kyustendil – 116,915 5.6 7.3 7.0 14.5 65.6 100.0 Lovech – 122,546 5.3 9.9 7.8 12.6 64.4 100.0 Montana – 127,001 4.4 9.3 7.5 11.5 67.3 100.0 Pazardjik – 252,776 5.9 15.3 10.4 17.2 51.2 100.0 Pernik – 119,190 4.5 8.2 11.6 11.8 63.9 100.0 Pleven – 236,305 6.2 12.1 8.7 10.6 62.4 100.0 Plovdiv – 666,801 8.1 11.7 7.1 14.6 58.5 100.0 Razgrad – 110,789 9.7 16.2 6.9 18.4 48.7 100.0 Ruse – 215,477 11.0 16.1 11.8 14.6 46.5 100.0 Silistra – 108,018 5.5 10.2 9.2 15.7 59.4 100.0 Sliven – 184,119 11.2 16.2 9.3 14.2 49.0 100.0 Smolyan – 103,532 7.2 15.9 11.6 16.7 48.6 100.0 Sofia - capital – 1,328,790 7.6 13.9 9.2 13.1 56.2 100.0 Sofia District – 226,671 6.8 11.6 8.1 11.9 61.5 100.0 Stara Zagora – 313,396 10.8 16.1 7.4 12.1 53.7 100.0 Targovishte – 110,914 7.7 12.3 10.6 21.3 48.1 100.0 Haskovo – 225,317 9.2 17.5 8.9 17.3 47.1 100.0 Shumen – 172,262 5.4 13.0 8.4 16.4 56.8 100.0 Yambol – 117,335 7.8 13.0 6.1 11.9 61.2 100.0 Total by age groups 7.4 12.9 9.0 14.4 56.3 100.0 Source: Based on Table 4.5. The data show that persons with disabilities over 65 years of age dominate. This is not unexpected, given empirically established fact that disability prevalence and severity of disability increase with age.134 What is not expected is a huge district variance in the rates of persons with disabilities for whom TMECs/NMEC have determined the need for personal assistance (calculated per 1,000 district population). The rates vary from 1.3/1,000 population in Sofia to 11.3/1,000 population in Pleven (the average for Bulgaria in the observed period was 3.3/1,000 population). Given that the INA only 134 The World Health Organization and The World Bank. 2011. The World Report on Disability. Geneva, New York and Washington, D.C. https://www.who.int/teams/noncommunicable-diseases/sensory-functions- disability-and-rehabilitation/world-report-on-disability 89 determines the level of dependency and a corresponding number of hours of personal assistance, these differences reflect the TMEC/NMEC decisions regarding the degree of disability and the need for personal assistance. While some variance can be explained by differences in the population age composition and morbidity patterns, it is large, and it likely reflects the manner how various TMECs assess disability (see Chapter 3 for discussion). In any case, the data signals the need for a thorough empirical analysis of the observed patterns, including juxtaposing TMEC data on 90+ degree of disability and the need for personal assistance with SAA data on the dependency level and the hours of personal assistance determined through the individual needs assessment. 4.7. Administrative Process of the individual needs assessment under the Social Service Act (SSA) As mentioned, the Social Service Act (SSA) describes an individual needs assessment (we call it a SSA INA) process as part of the individual support plan that is a precondition for the provision of services provided by SSA. None of the benefits and services mentioned in the needs assessment under PDA discussed above require an additional SSA needs assessment. Only if the Report on the PDA INA decides that SAA should issue a direction (referral) that 'other social services' are required, then this process begins. The person takes the SAA direction to the social service provider that then organizes an individual assessment of needs and develops an individual plan of support to the person.135 There is no uniform or standardized procedure for conducting this assessment of individual needs for services.136 The SSA needs assessment must be conducted within 20 days after it is requested by a person (or 30 days, if the person cannot attend) and conducted by at least a two-member 'team' of employees of the social service provider. Beyond this, all that is said about the nature of the assessment itself is that the team shall prepare an SSA INA “… applying the rules and methods of work in providing the service (interviews, tests, meetings and interviews with the applicant and her/his relatives, examination of documents and opinions of specialists, analysis of the home/family environment, observations and/or other methods at the discretion of the team.137 Based on this individual needs’ assessment, a social service provider can make one of the following decisions: a) The applicant is suitable for the service and, if the provider has the capacity to take in the person, the provider starts preparing an individual plan and the contract for the use of service;138 b) The applicant is suitable for the service, but the provider has no capacity to accommodate her/him, in which case the applicant is placed on a waiting list;139 c) The application is declined with a motivated refusal.140 Motivated refusal is issued if the requested social service is found not suitable for the person’s needs. 135 Article 25(1) of the Regulation on the Implementation of the Social Service Act. https://www.lex.bg/bg/laws/ldoc/2137207105. 136 There is anecdotal evidence that the assessment is conducted by a multidisciplinary team (often a psychologist, social worker, rehabilitation professional and other specialist therapist). Medical and other documents are reviewed, and the applicant and her/his family members are interviewed. 137 Article 25(2). Ibid. 138 Article 25. Ibid. 139 Article 79. Ibid. 140 Article 20, paragraph 2 of the Regulation on Implementation of the Social Service Act, ibid. 90 Social Assistance Agency and Individual Needs Assessment As noted, individual needs assessments under the Persons with Disabilities Act are conducted by employees of a specialized unit called the Social Assistance Directorate (SAD) within the territorial divisions of the Social Assistance Agency (SAA). The total number of the SAA’s territorial agencies is 148 covering all municipalities in Bulgaria. Large cities such as Sophia have more than one territorial agency. In small municipalities there may be no agency but instead a “mobile(external) office” staffed by social workers from the nearest SAD would visit on scheduled weekdays. The activities of the SAA are organized by the policy and budget program.141 There are 3 policies: 1) policy for social protection and equal opportunities comprising two budget programs: social aid provision and provision of hearing aids for lower income individuals; 2) policy for persons with disabilities with one budget program on the Integration of persons with disabilities, bringing together functions of the SAA under the PDA, the PAA and other legislation, including the individual needs assessment; and 3) policy on social inclusion with budget programs on child protection through transition from institutionalized support to alternative support in the family environment and support to families with children. Table 4.6 presents total expenditure of SAA by type of activity: Table 4.6: SAA expenditure 2019 Type of expense Amount in BGN Total 1,258,165,800 Departmental expenditure 79,474,323 Budget programs 1,138,142,477 EU funded projects; funded by other ministries 40,549,000 Source: Social Assistance Agency The resources allocated for the budget program Integration of Persons with Disabilities are divided into operating costs and staff costs. Capital expenditure is not allocated to a budget program. Table 4.7 presents the SAA expenditure on INA and the total expenditure for the relevant budget program for 2019.142 Table 4. 7: SAA expenditure on the budget program Integration of persons wit h disabilities and on the individual needs assessment 143 in 2019 Budget program Integration of INA (BGN)144 persons with disabilities (BGN) Capital expenditure 850,000 Operating costs 1,000,000 6,785,000 Staff cost 9,953,600145 62,650,000 Source: Social Assistance Agency 141 Budget of the Social Assistance Agency. https://asp.government.bg/bg/za-agentsiyata/byudzhet 142 The data provided by the Social Assistance Agency. 143 The budget program includes benefits to persons with disabilities under PDA administered by SAA and personal assistant expenditures (excluding support to children with disabilities). 144 Budget of the Social Assistance Agency for 2019. https://asp.government.bg/uploaded/files/448-budjet-na- ASP-za-2019.pdf 145 Data officially provided by SAA on request. 91 The total number of employees involved in individual needs assessment, either full or part-time is 694. They occupy positions of “social workers.146 The number of employees in SADs varies according to the population number in the municipality. The employees have at least a secondary education, but those who are designated to conduct INA have a university degree.147 Very few have a degree in social work. The pay is considered relatively low, and the employee turnover is high, causing a constant shortage of staff. Individual needs assessments are performed by two professional positions: a social worker and a chief social worker. There are 88 chief social workers in Bulgaria, and 606 social workers. Most of the chief social workers have university degree. Among social workers, 249 hold a master’s degree and 201 hold a bachelor’s degree. There are 46 employees with professional education148 and 110 with secondary education only. The average gross salary of the chief social worker is 1,561 BGN and of the social worker 1,161 BGN. With regard to the workload, it is reported by MLSP that it takes about half an hour for the preparation of an INA without the full assessment of the functional difficulties and 2 hours for an INA with full assessment of functional difficulties.149 However, from discussions with staff, the preparation of an INA for one person, including reviewing documents, visiting the person’s home and conducting interviews, filling out the forms and preparing draft conclusions takes 8 or more working hours. This does not include meetings, preparing referrals is they are needed, drawing up notification that the assessment is completed, etc. 4.8. Key messages The introduction of the individual needs assessment of persons with disabilities is a very important step in the implementation of the United Nations' Convention on the Rights of Persons with Disabilities. In 2019, the Person with Disabilities Act introduced a complex INA in Bulgaria. This is a very important step in the implementation of CRPD that mandates that persons with disabilities have the right to the provision of health and social services "based on the multidisciplinary assessment of individual needs and strengths". In the context of health and social welfare programming for persons with disabilities, an INA is a tool that identifies what a person requires in terms of supports and services in response to needs that are created by problems in functioning that result from an underlying health problem – disease, injury or other condition that results in one or more impairments of body functions or structures. As implemented in practice, PDA INA is yet to be consistent with the modern concept of disability. Article 20 of PDA created the legal right of persons with disabilities to a complex and individual assessment of needs that examines "the functional difficulties of a person with a disability, related to her/his health condition and the presence of barriers in the performance of daily and other activities, as well as the type of support needed." This statement reflects the concepts of functioning and disability found in the World Health Organization's International Classification of Functioning, 146 Data provided by SAA. 147 The reason that higher education is not required is that there are vacancies in the local structures of SAA which do not offer attractive payment levels, while a university degree is usually needed for higher administrative functions. 148 The type and level of professional competence is not specified by SAA. 149 The discrepancy might be due to a misunderstanding. When the SAA representatives were asked why such information is provided, they answered that this is a misunderstanding. The mentioned of 2 hours as a duration is only concerning the time needed for the interview with the person with disabilities. 92 Disability and Health, and as well the CRPD's characterization of 'persons with disabilities'. There is, however, no further mention of the ICF in either PDA or its PDA Regulation. The link between PDA INA and the ICF is most clearly made in Article 1 of the Methodology for Conducting an Individual Assessment of the Needs for Support to Persons with Disabilities (The Needs Assessment Methodology - NAM). However, the characterization of the ICF 'bio-psycho-social model” is somewhat confused. For although disability is described as a problem in functioning (or 'functionality' as it is termed), functionality itself is characterized as a capacity of the body not, as in ICF, the outcome of an interaction between the capacity of the body and environmental factors. Moreover, unlike the ICF, the environment – called 'possibilities' – is described as preventing "the person with a disability from fulfilling its functionality through relevant actions," rather than, as in the ICF, creating the level of functionality in the person's performance of activities. As these differences are fundamental, it is hard to say that the current INA described in NAM is consistent with the ICF. Currently PDA INA plays a limited role. Within the current context of medical certification of disability and eligibility rules for support measures to persons with disabilities, INA plays a very limited role. Decisions on the needs for important support measures, such as personal assistance or the need for technical aids is de facto made by TMECs/NMEC as part of the disability certification. Thus, INA serves as an instrument to determine the level (hours) of personal assistance and as eligibility screening tool for measures administered by SAA or a referral tool for measures implemented by other government bodies (where, such as the case of social services, additional needs assessment may be conducted). Medical approach to disability permeates. As discussed in Chapter 3, the certification of disability in Bulgaria is exclusively made based on medical criteria. In addition, the social worker form (in Part 3) introduces the notion of “functional insufficiency” (intellectual, physical, psychological, sensory and “other illnesses”) in a “yes”/”no” answer format, which has nothing to do with functioning, but it seems to pertain to impairment/medical diagnosis. Information on functioning is collected only in the case when a person requests personal assistance. Thus, it is difficult to understand how the needs are assessed without first assessing problems in functioning experienced by a person with a disability in her/his home, community, and work environment. The tools used for INA reflect the context and overall heavy focus on disability as a medical issue. Looking at the tools, the following is observed: The Social Worker Form 1) Part 2: Medical Expertise Findings and Part 3 Information on the functional insufficiency/health condition of the person with disability are unnecessary as the full NMEC/TMEC/MAC report should already be available. In addition, Part 3 introduces a completely different concept ('functional insufficiency') that serves no function in the assessment. 2) Part 4: Information on the existing problems with the functioning of the person with disabilities and Part 5: Information on the impact of constraints on the life of the person with disability are only used to determine the level of dependency and the number of hours of personal assistance. It is far more detailed than is required for that purpose. In addition, in parts 'total scores' are calculated merely by adding up the scores for each question, but the result is technically questionable since the scores for each question are not comparable and cannot be added together. Moreover, the initial score is augmented by coefficients, but it is not clear why and which methodology was used to determine them. This total score is then brought forward in 7.3 Need for personal assistance. There is no justification or rationale for how this total score affects the decision. 93 3) Part 6: Participation in education or on the labor market only asks the open-ended question 'What kind of support is the person with disability applying for?' but gives no indication of whether that support is needed or on what basis that decision is made. 4) Part 7: People surrounding the person with disability and need for social services/personal assistance, Part 8: Targeted aid, and Part 9: Provision of monthly financial support merely record the social worker decisions about several kinds of supports (personal assistance, housing, technical aids and medical devices, financial support for motor vehicle, balneological treatment and/or rehabilitation services, monthly financial support) without any indication of how that decision is made or on what basis. 5) Part 10: Wishes of the person with disability and additional information merely repeats information already collected or asks about the persons motivation for social integration. Again, there is no indication how this information is used. In summary, the social worker form either collects information already collected (parts 2,3) or records the case responsible social worker decision about a specific need without indicating what evidence was used or what the basis for the decision was. The scoring mechanism is technically questionable as it is not technically founded to simply add up scores from different domains because, inter alia, they are not commensurable. The Self-assessment Form The Self-assessment Form is a long list of question, including a series of questions in seven domains of functioning with answers in a “yes” and ”no” format. Many questions pertain to demographic information that should already be available from TMEC/NMEC and civil registry. The “yes”/”no” format severely limits the value of information that is collected through this questionnaire. Conversation with social workers suggests that many persons with disabilities find it difficult to fill in the questionnaire. Moreover, the self-assessment plays a limited role in the assessment. Administrative process to apply for the individual needs assessment is onerous. The applicants are required to submit documents most of which should be available in the Civil Registry, Information System for Control of Medical Expertise/Regional Files of Medical Expertise Medical Files, Social Security Institute, National Employment Agency, Tax Administration, etc., and an applicant should not be asked to provide them, save for an application, identity document and a self-assessment form. Even an application submission could be eliminated and each person who has gotten a certificate from TMEC/NMEC (or a referral from MAC) could automatically be referred to SAD for a needs assessment. A referral could also include (agreed) documents. A person with a disability could be then invited to submit a self-assessment and indicate which service she/he would wish to receive. Ideally, parts of the needs assessment templates should be populated automatically, including personal information, TMEC/NMEC certificate information. Methodological guidelines and instructions on how to conduct PDA INA need strengthening. Existing guidelines, methodological explanations, and instructions on how to conduct INA need to be strengthened by detailed explanation of what is meant by description of each qualifier in each domain, use of vignettes, how to observe cross dependency across domains and spot inconsistencies that require further probing. Instructions on how to assess the environment need expansion too. Collecting information on functioning necessitates deep understanding of functioning and a modern concept of disability as conceptualized by ICF. Considering that the needs assessment is new, and that the implementation thus far could be considered as trial and learning period, based on the above observations, we recommend: 94 • Revise the needs assessment tools to collect information on problems in functioning, identify the needs whose fulfillment within the existing services and support measures can improve functioning (or experience of persons with disabilities in their everyday life) and, considering wishes of persons with disabilities, link (refer) them to the support measures and institutions that provide them. Save for the TMEC/NMEC decision, eliminate medical information from the needs assessment tools. • Apply a full needs assessment to all persons with disabilities. This might be time and effort consuming, but the rollout could be gradual. • Consider having TMEC/NMEC/MACs recommending (not deciding on) support measures and make decisions only after a full functioning and needs assessment has been completed. • Simplify administrative process by introducing an automatic referral from TMEC/NMAC to individual needs assessment, minimizing documents requirements from an applicant and using extensive information system already in operations to automatically pull out personal and other information and documents. • Modify a self-assessment form to focus it on environmental questions (barriers and facilitators) and a select ICF categories with rating scale 0-4, not YES and NO modality. • Prepare expanded and strengthened technical guidelines and methodological instructions and regularly (re)train staff in their implementation. • Establish a technical and methodological individual needs assessment unit in SAA (or the Disability Policy Directorate of MLSP) that would conduct econometric and statistical analysis of the INA data and monitor the trends. 95 Chapter 5: Public measures to support persons with disabilities In this Chapter we present an overview of public measures specifically provided to persons with disabilities and or their caregivers in Bulgaria. It should be noted that in addition to disability specific measures, persons with disabilities can benefit from all other social programs, like any other citizen of Bulgaria, if they meet eligibility requirements. Bulgaria provides a wide range of support measures to persons with disabilities through social security, social assistance, social services, labor market, public health, and other programs. Benefits range from financial support, to care services, social, medical, and vocational rehabilitation, employment support, to residential placement, as well as benefits such as tax reduction, free/subsidized transportation, discounted entry into museums, etc. Support is provided both by the state and municipalities. Support to persons with disabilities is regulated by various laws and associated regulations of the Council of Ministers and other relevant government bodies. Annex 4 to this Report presents detailed information on public support measures provided specifically to persons with disabilities, including programs’ detailed description, eligibility requirements, level of benefits, administrative procedures to get the support and for grievances and their redress and implementation and financing arrangements and entities. Detailed statistics is provided in Annex 1 to this Report. In this Chapter, we will not provide details, instead, we present summary statistics and issues observed during information collection and discussions with various stakeholders. 5.1. Disability specific support measures Below is the list of key disability specific programs to support persons with disabilities. Many comprise several types of benefits. i. Family allowance for children with disabilities ii. Disability social security pension and a supplement for assistance/care from other people iii. Financial assistance to adults with disabilities iv. Targeted disability allowance v. Targeted support for technical aids and compensation of transport costs incurred for the purpose of acquiring assistive devices, medical equipment, and other technical aid vi. Free yearly electronic vignette for road tall vii. Social services for children with disabilities viii. Social services for adults with disabilities ix. Assistant’s services for persons with disabilities – under the Employment Promotion Act x. Personal assistance to persons with disability (under the Personal Assistants Act) xi. Measures to support employment of persons with disabilities (wage subsidies, support for entrepreneurship, employment quotas, job search assistance, special enterprises for persons with disabilities) xii. Tax reductions for persons with disabilities and for parents of children with disabilities xiii. Other benefits. Across the board, to access disability specific support measures, persons with disabilities are required to have a certificate issued by TMEC/NMEC, certifying that a person is assessed as having at least 50 percent disability. In some cases, some benefits such as technical aids can be accessed at the recommendation of a MAC during the sick leave. In addition, for some programs, such as assistant’s services or a social security allowance for assistance by other people or technical aids, a TMEC/NMEC 96 decision specifying that a person needs this benefit is needed. A comprehensive individual needs assessment is needed as well. Also, each program has its own eligibility requirements (family situation, income, etc.). As noted, see Annex 4 to this Report for the programs’ eligibility requirements and other details. 5.2. Public spending on support measures specific to persons with disabilities According to the Eurostat data, Bulgaria spent 16.1 percent of GDP on social protection in 2019 (slightly down from 16.4 in 2018), well below the European Union (EU) average of 26.9 percent of GDP (up from 24.6 percent in 2018) (Figure 5.1). Figure 5.1: Public expenditure on social protection benefits in Europe 2019 The spending on social protection has grown relatively fast in real terms between 2010 and 2019 – at an average annual rate of 3.2 percent, one of the highest rates among the EU countries (the EU average was 1.4 percent).150 Spending on disability benefits grew at 4.3 percent per year relative to 1.5 percent for the EU-27. In terms of GDP share (Figure 5.2 and Table 5.1), the public spending on disability is below the EU average (1.3 compared to 2.1 percent of GDP in 2019, respectively). To a certain extent, one would expect this, given that Bulgaria, according to the EU SILC (see Chapter 1), has a self-reported disability rate of 16.4 percent151 (2019), which is one third below the EU average of 24.6 percent and one of the lowest rates among the EU countries covered by EU SILC. At that, 80.0 percent self-reported “some” disability, and only 20.0 percent (or 3.2 percent of the population 16 and older) self-reported severe disability.152 On the other hand, spending on disability as a fraction of the overall spending on social protection is higher in Bulgaria relative to the EU average – 8.3 and 7.6 150 See: https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Social_protection_statistics_- _social_benefits 151 The differences between the self-reported disability rates as collected by EU SILC and administrative data of persons certified as disabled are explained in Chapter 1. 152 A food for thought: the EU SILC reports 16.1 percent of self-reported disability rate of which 20.0 percent (3.2 percent of the population aged 16 and over) self-report severe disability. Administrative data of certified disability shows a rate of 10.8 percent in total population (including children younger than 16) of which half (5.4 percent of all population was certified as having severe disability (a degree of over 70 percent). 97 percent, respectively (Figure 5.3, Table 5.1), showing significant investment Bulgaria is making to support persons with disabilities. At the same time, it should be noted that data presented in Table 5.2(1) and 5.2(2) – section on Disability pensions – show that in 2019, 1.5 percent of GDP was spent on disability pensions only (1.7 percent in 2021). This should be clarified because it could be that disability pensions are not accounted for fully in the reported spending on disability in Table 5.1. Figure 5.2: Public expenditure on disability benefits as % of GDP in EU and some other European countries 2019 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 EU-27 Finland Iceland Serbia Turkey Montenegro France Italy Latvia Austria Romania Norway Denmark Greece Cyprus Hungary Spain Netherlands Croatia Poland Bulgaria Germany EA-19 Ireland Malta Slovenia Belglum Luxembourg Slovakia Estonia Portugal Sweden Lithuania Switzerland Czechia Bosnia and Herzegovina Source: Eurostat. Figure 5.3: Spending on disability benefits as % of total social protection spending in EU and some other European countries in 2019 18 16 14 12 10 8 6 4 2 0 EU-27 Austria Latvia Iceland Serbia Turkey Denmark Montenegro EA-19 Ireland France Italy Hungary Romania Finland Norway Bulgaria Greece Spain Croatia Cyprus Germany Luxembourg Netherlands Poland Slovenia Belglum Estonia Lithuania Malta Slovakia Portugal Sweden Czechia Bosnia and Herzegovina Switzerland Source: Eurostat. 98 Table 5.1: Expenditure on social protection (SP) benefits by function 2019 Old age and Sickness / Family / Housing and Disability Unemployment survivors Healthcare Children Social Exclusions % of % of % of % of % of % of % of % of SP % of SP % of SP % of SP % of SP SP GDP GDP GDP GDP GDP GDP EU-27 46.3 12.5 29.5 8.0 7.6 2.1 8.4 2.3 4.5 1.2 3.7 1.0 EA-19 46.1 12.8 30.0 8.3 7.4 2.1 8.0 2.2 4.8 1.3 3.7 1.0 Belgium 46.8 12.9 27.3 7.5 9.3 2.5 7.7 2.1 5.6 1.5 3.5 0.9 Bulgaria 47.4 7.6 30.2 4.9 8.3 1.3 10.0 1.6 2.9 0.5 1.3 0.2 Czechia 47.3 8.7 33.7 6.2 6.2 1.1 9.0 1.6 2.2 0.4 1.7 0.3 Denmark 41.3 12.4 21.2 6.4 15.8 4.7 10.9 3.3 4.2 1.2 6.6 2.0 Germany 38.5 11.2 35.7 10.4 8.7 2.5 11.6 3.4 3.2 0.9 2.4 0.7 Estonia 40.8 6.6 29.1 4.7 11.6 1.9 14.4 2.3 3.3 0.5 0.8 0.1 Ireland 34.3 4.5 39.4 5.2 5.7 0.7 10.0 1.3 5.9 0.8 4.7 0.6 Greece 64.1 15.9 19.7 4.9 4.4 1.1 6.2 1.5 4.0 1.0 1.7 0.4 Spain 51.6 12.2 27.3 6.5 6.9 1.6 5.6 1.3 7.2 1.7 1.5 0.3 France 45.5 14.3 28.6 9.0 6.5 2.0 7.4 2.3 6.1 1.9 6.0 1.9 Croatia 42.7 9.1 33.8 7.2 10.0 2.1 9.2 2.0 2.8 0.6 1.5 0.3 Italy 58.5 16.6 22.8 6.5 5.6 1.6 4.0 1.1 5.5 1.6 3.6 1.0 Cyprus 53.2 9.7 25.2 4.6 4.1 0.7 5.8 1.1 5.0 0.9 6.8 1.2 Latvia 46.8 7.2 29.3 4.5 8.5 1.3 10.4 1.6 4.0 0.6 1.0 0.2 Lithuania 43.3 7.0 30.5 4.9 8.7 1.4 10.8 1.7 4.6 0.7 2.1 0.3 Luxembourg 40.0 8.5 25.8 5.5 10.4 2.2 15.5 3.3 5.6 1.2 2.8 0.6 Hungary 49.5 8.1 28.4 4.6 5.8 0.9 11.4 1.9 1.9 0.3 3.0 0.5 Malta 50.8 7.7 36.6 5.6 3.7 0.6 5.6 0.9 1.2 0.2 2.1 0.3 Netherlands 41.6 11.3 34.8 9.4 9.3 2.5 4.6 1.2 3.1 0.8 6.6 1.8 Austria 50.6 14.5 26.7 7.6 6.2 1.8 9.2 2.6 5.4 1.5 1.9 0.6 Poland 53.0 11.1 24.1 5.1 5.6 1.2 14.5 3.0 1.1 0.2 1.7 0.4 Portugal 57.1 13.3 26.7 6.2 7.2 1.7 5.2 1.2 2.8 0.7 0.9 0.2 Romania 52.2 7.8 29.8 4.5 5.9 0.9 11.2 1.7 0.3 0.0 0.6 0.1 Slovenia 46.7 10.2 34.1 7.4 4.9 1.1 8.4 1.8 2.3 0.5 3.7 0.8 Slovakia 45.4 7.9 32.6 5.7 8.4 1.5 9.3 1.6 2.9 0.5 1.5 0.3 Finland 46.1 13.6 22.9 6.7 9.6 2.8 10.0 3.0 5.5 1.6 5.9 1.7 Sweden 45.4 12.3 27.4 7.5 9.7 2.6 10.7 2.9 2.9 0.8 3.9 1.1 Iceland 31.4 7.6 36.2 8.8 15.8 3.8 10.1 2.5 2.3 0.5 4.3 1.0 Norway 38.4 10.1 28.4 7.5 16.5 4.3 11.7 3.1 2.0 0.5 3.0 0.8 Switzerland 47.8 12.0 31.9 8.0 7.9 2.0 5.9 1.5 3.1 0.8 3.5 0.9 Montenegro 51.9 8.4 29.6 4.8 8.5 1.4 4.2 0.7 3.2 0.5 2.5 0.4 Serbia 54.9 10.5 27.0 5.2 5.5 1.1 6.5 1.2 3.0 0.6 3.1 0.6 Turkey 61.6 7.2 27.5 3.2 3.4 0.4 3.8 0.5 2.3 0.3 1.3 0.2 Bosnia and 50.9 9.4 29.3 5.4 11.5 2.1 4.5 0.8 2.6 0.5 1.3 0.2 Herzegovina Source: Eurostat. 99 5.3 A snapshot of programs, beneficiaries, and spending153 As noted, only persons formally certified by TMEC/NMEC as having a disability degree of at least 50 percent can access disability support measures. Different programs require different degree of disability, with some available only to persons with a degree of disability >90.0 percent. For several benefits the TMECS’ decision that a person should be assisted by others is needed as well. A review of programs to support persons with disabilities shows that persons with disabilities are required to apply for each disability benefit separately (a demand-based approach), even in cases when several benefits are administered by one agency. This supposes that they know which benefits are available and how to access them (for technical aids and rehab services people are asked to find providers by themselves, as well), which is mostly not the case. While each implementing agency is mandated to provide pertinent information on its website, there is no integrated information available in one place and no single entry through the government portal to access it. Often, persons with disabilities are asked to submit same documents repeatedly, despite the existence of several management information systems that are supposed to contain a comprehensive information on each person with disabilities and be able to formally exchange them. Financial benefits and targeted support measures (financial and non-financial) are open ended and each person who requests the benefit and passes eligibility requirement receives it. This is not the case with social rehabilitation and social welfare and care services where approached service provider may reject the service request or waitlist the customer. The above observations call for the disability system improvements. First, a much better information on various programs available to persons with disabilities is needed. An information booklet with all programs, including their eligibility requirement and how and where to apply for them should be available in regularly updated electronic and printed formats. The printed booklet should be handed to each person applying to TMEC/NMEC. Ideally, this information should be compiled and maintained by the government body responsible for the coordination of disability policy as it requires inputs from various agencies at the national, regional, and local levels of government. Second, an integrated management information system is needed to enable automatic information flow between various relevant agencies: from the health system, including MACs to TMECs/NMEC; from TMECs/NMEC to SSI and SAA; from SAA to government departments implementing various programs (as a referral together with the needs assessment and an action plan), etc. This should not be difficult to achieve, as Bulgaria has several information systems that could be linked into an integrated system that would make information flow smooth, decision making easier, and the beneficiaries’ journey through the system less complex and onerous. Third, the linkages between disability certification (TMEC/NMEC), a complex, individual needs assessment (SAA), an action plan development (developed by SAA in a multidisciplinary fashion), referral (SAA) and access to services (persons with disabilities, service providers) ought to be much tighter. Finally, a database on persons with disabilities, currently maintained by the Agency for People with Disabilities of MLSP, which contains extensive information on everyone with disability in Bulgaria, should be able to also collate information on benefits they receive. The data should be available to program administrators from various government departments in carrying out their official duties, to 153 See Annex 1 to this Report for detailed statistical information. 100 policy makers, and, in anonymized format, to the public for research. This data base contains important empirical data that should be used for evidence-based disability policy development and monitoring of its implementation. (i) Family allowance for children with disabilities This is a universal monthly allowance for raising a child with disability provided to their mothers. It is regulated by the Family Allowances Act (FAA)154 along with other targeting allowances for children. Available to all children up to 16 years of age certified by TMEC/NMEC as having a disability, or reduced work capacity for children older than 16 (until completion of secondary education, but not later than 20 years of age). The benefit amount is determined yearly by the National Budget Act.155 The amount depends on the degree of disability. In 2020, they were: (i) Level 3: disability degree of at least 90.0 percent - 930 BGN; (ii) Level 2: 70-90 percent degree - 450 BGN; and (iii) Level 1: 50-70 percent degree 350 BGN. As a reference, the minimum wage in Bulgaria in 2020 was 311.89 BGN (June 2020). Table 5.2: Monthly family allowance for children with disabilities, beneficiaries, and expenditure 2017-2019 2017 2018 2019 Expenditure Expenditure Expenditure Beneficiaries Beneficiaries Beneficiaries BGN BGN BGN Family allowance for children with 26,393 161,500,024 26,395 170,816,806 25,717 169,023,894 disabilities Source: Social Assistance Agency (ii) Targeted allowance to children with disabilities The FAA envisages additional support for children with disabilities: (i) a one-off payment156 to a mother for the delivery of a child with 50 percent of disability determined by the child’s second birthday (100 BGN in 2020); (ii) a one-off payment granted to children with disabilities for enrolling in the 1st and 8th grade in school. For further details and statistics see Annex 1 and Annex 4 to this Report. (iii) Disability pensions and supplement for assistance by other people Disability pension According to the Bulgarian Social Security Code (SSC)157 working age persons with disabilities are eligible to a disability pension. Several types of disability pensions are provided: Disability pension unrelated to work experience: persons who have acquired disability when on military or civic duties. The pension amount is calculated as a percentage of the old age social pension 154 , Article 2 and Article 8d of the Family Allowances Act: https://www.lex.bg/laws/ldoc/2135441920 155 Article 62 of the Budget for 2020: https://www.minfin.bg/upload/45899/Zakon+Budget+2020.pdf 156 Article 6, paragraph 6 of the Family Allowances Act. Ibid. 157 Article 71-79 of the Social Security Code, https://www.nssi.bg/images/bg/legislation/Codes/KCO.pdf. 101 depending on the degree of disability. In 2020, this disability pension ranged from 162.87 BGN to 226.61 BGN.158 Social disability pension: provided to persons with disability with no work experience and no social security contributions. A minimum of 71 percent of reduced work capacity is required. The social pension monthly amount depends on the degree of disability and ranges from 155.79 BGN to 169.96159 (2020). Disability pension: provided based on work experience and paid social security contributions. The required minimum degree of reduced work capacity is 50 percent.160 This pension could be due to general illness or due to work accident or occupational illness.161 Disability pension can be personal or survivor. The pension is awarded for the duration of disability (mostly 3-5 years), after which the person must be recertified by TMEC, or should return to the labor market. Disability pensioners can work and receive remuneration in addition to the pension. Persons with disability who receive a social disability pension, have the option to change their type of pension to a disability pension, if they obtain a minimum of one year of work experience if their disability was acquired at birth or before the age of 20. For all other cases there are different mandatory work experience requirements, and they depend on the person’s age: For blind persons - born blind or has become blind before reaching 20 years of age: work experience is not required, • For persons up to 25 years of age: a minimum of 1 year, • For persons up to 30 years of age: a minimum of 3 years, • For persons older than 30 years a minimum of 5 years is required. Tables 5.3(1) and 5.4(2) present data on disability pensions recipients and related public expenditure in 2019 and 2021. 158 Starting with 115 percent to up to 160 percent of the social old-age pension (141.63 BGN as of July 1, 2020, Decision of the Council of Ministers № 107/ 28.05.2020 г. https://www.noi.bg/images/bg/legislation/decree/pms-107-2020.pdf). 159 Between 110 and 120 percent of the social old-age pension. 160 For working age adults (16-64) the term “level of disability” is not applicable; instead, the term “level of reduced work capacity” is used. Both denote disability. 161 “Professional illness” is a disease resulting from harmful factors in the work environment or labor processes and is included in the list of professional illnesses approved by the Council of Ministers. Employees with a labor contract are insured against occupational disease/work accident through a Social Security Fund for Work Accidents and Professional Illness. 102 Table 5.3 (1): Disability pensions in Bulgaria: beneficiaries, average pension, and expenditure 2019 Average Average Average pension of a Expenditure, number of number of pensioner annual, 000 pensioners pensions per month BGN BGN TOTAL Social Security 2,145,271 2,162,013 383.0 9,860,527 Pension Fund 1,984,079 1,988,472 375.4 8,885,971 Of which: Disability pension – general disease 451,793 453,729 268.8 1,618,066 Disability others (farmers and COOP) 1,104 1,117 291.1 3,849 Under Art. 69 Fund Of which: Disability, general disease 58 58 342.9 250 Pensions not related to Labor Activity 59,786 62,649 181.3 153,341 Fund Of which: Disability military 2,333 4,587 193.6 9,098 Disability civil 135 242 194.8 404 Social Disability Pension 50,659 50,981 186.2 123,010 Accidents at work/occupational diseases Fund Related to employment 7,343 16,979 316.9 39,489 Under Art. 69 10 22 349.2 86 DISABILITY PENSIONS TOTAL 513,435 527,715 261.1 1,794,252 Relative to SSI Total (%) 23,9 24,4 68,2 18,2 Reference: GDP in 2019=$69,2 billion (BGN 120,4 billion); average monthly social pension for old age = 144,67 BGN; average old age social security pension under Pension Fund = 406,88 BGN; minimum wage=560,0 BGN; poverty line=348 BGN). 1 USD = 1.74099 BGN (December 31, 2019). Source: National Social Security Institute 103 Table 5.4 (2): Disability pensions in Bulgaria: beneficiaries, average pension, and expenditure 2021 Average Average Average pension of a Expenditure, number of number of pensioner annual, 000 pensioners pensions per month BGN BGN TOTAL Social Security 2,080,454 2,094,528 536.7 14,249,162 Pension Fund 1,926,413 1,930,014 528.5 13,150,397 Of which: Disability pension – general disease 438,476 440,099 399.2 2,037,240 Disability others (farmers and COOP) 890 896 443.9 4,168 Under Art. 69 Fund Of which: Disability, general disease 45 45 498.0 245 Pensions not related to Labor Activity 59,137 61,210 273.9 171,249 Fund Of which: Disability military 2,076 4,056 292.2 10,200 Disability civil 115 208 289.1 403 Social Disability Pension 50,276 50,276 280.1 139,007 Accidents at work/occupational diseases Fund Related to employment 6,306 14,682 462.9 44,816 Under Art. 69 8 14 442.3 93 DISABILITY PENSIONS TOTAL 498,192 510,276 387.6 2,236,171 Relative to SSI Total (%) 23,9 24,4 72,2 15,7 Reference: GDP in 2021=$75,6 billion (BGN 130,6 billion); average monthly social pension for old age = 224,06 BGN; average old age social security pension under Pension Fund = 566,72 BGN; minimum wage=650,0 BGN; poverty line=369 BGN). USD = 1.72685 (on December 31, 2021). Source: National Social Security Institute Data in the above tables show a sharp increase in average disability pension (across all types of disability pensions by 48.0 percent between 2019 and 2021. Total spending in nominal terms increased by 24.6 percent. Supplement for assistance by other people Persons with disability for whom a TMEC has concluded that they need assistance from other people are eligible to a disability pension supplement. In 2020, this supplement was 106 BGN162 per month (it is calculated as percentage of the old age social pension). The supplement is paid as part of the 162 External support supplement is 75 percent of the social pension for old age. 104 pension, and it lasts until the disability pension expires. Table 5.5 presents data on the disability pension supplement for assistance by other people. Table 5.5: Disability pension supplement for assistance by other people – recipients and expenditure 2018 – 2021 2018 2019 2020 2021 Expenditure Expenditure Expenditure Expenditure Recipients Recipients Recipients Recipients (BGN) (BGN) (BGN) (BGN) 77,515 90,432,945 73,637 89,915,585 71,367 92,706,470 66,388 92,800,851 Source: National Social Security Institute Data presented in Chapter 1, Statistical Annex and Tables 5.5 and 5.6 allow for several conjectures. First, there seem to be a full coverage of working age adults with disabilities (288,025 persons in 2019) by a disability pension. It would also seem that about one half of older adults with disabilities (65 and over) receive a disability pension. One can assume that those not receiving a disability pension receive an old-age social security pension or an old-age social pension. Overall, data suggest that all adults with disabilities are covered by a regular monthly income from social security. Second, the average monthly disability pension in 2019 was 261.1 BGN (due to general illness 269 BGN; military/civil duties 194 BGN, social disability pension 186 BGN, occupational/work accident 317 BGN). In 2021, the average monthly disability pension was 387.6 BGN (due to general illness 399.2 BGN; military/civil duties 292.2 BGN, social disability pension 280.1 BGN, occupational/work accident 462.9 BGN). While in 2019 the average disability pension was about 25 percent below the poverty line; in 2021, it was 5.0 percent higher than the poverty line. Third, there has been a decline in the number of beneficiaries of the disability pension supplement for disabled persons assessed by TMECs as in need of assistance by others (Table 5.5). This is likely linked to the introduction of the personal assistants to persons with disabilities program, which is more attractive (see Annex 4 to the Report) and appears less administratively complicated to access. (iv) Tax reductions for persons with disabilities and for parents of children with disabilities Tax reductions are regulated by the Income Taxation of Individuals Act.163 For persons with disabilities they are applied on their income as individuals, thus reducing their total taxable income. Total tax reduction is limited to 7,920 BGN (2020). It is applicable to all persons with disabilities regardless of the type of income, provided they have a TMEC/NEMC decision on disability of at least 50 percent. Tax reduction can be used for the period of the disability certificate validity. 163 Art. 18 of the Income Taxation of Individuals Act. https://nra.bg/document?id=4777 105 Table 5.6: Tax reduction for persons with disabilities 164 2017 2018 2019 Tax reduction: Total amount Total amount Total amount Persons Persons Persons in BGN in BGN in BGN On income declared by 55,803 269,247,559 56,882 281,966,243 50,897 279,250,512 persons with disabilities165 On income of persons with disabilities who have labor 78,821 495,340,669 contracts as declared by their employers166 Total in BGN 129,718 774,591,181 Source: The National Revenue Agency Overall, in 2019, 129,718 persons with disabilities benefited from the income tax reduction (Table 5.6167). The data shows that only about 51,000 persons with disabilities declared income on which they applied for the income tax reduction. In their case, the average tax reduction amount was 5,470 BGN. About 79,000 persons with disabilities (including working older adults – over mandatory retirement age) had a labor contract168 and for whom their employers sought the income tax reduction. In their case, the average income tax base reduction was 6,266 BGN. Tax reductions for parents of children with disabilities169 are also applicable to all types of income. To claim the benefit, a parent should declare a child with at least 50 percent degree of disability in her/his tax declaration. The reduction depends on the number of children and the amount is determined annually. Currently, it is 2,000 BGN170 per child with disability. Table 5.7: Beneficiaries and total amount of tax reduction for parents of children with disabilities 171 2017 2018 2019 Total Total Total amount, No. of Persons amount, amount, BGN persons BGN BGN Parents claiming tax reduction on their income declaration 3,180 6,502,181 3,216 6,639,715 3,091 6,415,324 On income of persons with disabilities who have labor contracts as declared by their employers 5,415 10,938,835 Total 3,180 6,502,181 3,216 6,639,715 8,506 17,354,159 Source: The National Revenue Agency 164 Consolidated, i.e., duplications are excluded. 165 Includes all types of income (e.g., income from rental property, civil contracts, etc.). 166 The employers are obliged to report this data since 2019. Includes only persons with income form a labor contract, including working pensioners. Persons in the first row of the Table 5.7. are excluded. 167 Note: the data show the amount by which the tax income tax base was reduced, not the income tax loss to the budget and income gained by those who benefited from the reduction of the tax base – those would depend on the tax rates. 168 This indicates that the employment rate of working age adults with disabilities was at about 25.0 percent (see next chapter on labor market participation of persons with disabilities). 169 Ibid, Art. 22. 170 For comparison, a tax relief for 1 child without disability is 200 BGN, for 2 – 400 BGN, and for 3 or more – 600 BGN. 171 The amounts exclude duplications. 106 In 2019, about 3,100 parents of children with disabilities claimed tax reduction (2070 BGN on average) – Table 5.7. In addition, employers sought income tax reduction for 8,500 employed parents of children with disabilities in the amount of 10.9 million BGN or a bit over 2,000 BGN per employed parent. Overall, parents of about 35.0 percent of children with disabilities benefited from tax reduction in 2019. (v) Monthly financial assistance to adults with disabilities This benefit was introduced in 2019 by the Persons with Disabilities Act: adults with permanent disabilities/reduced work capacity of at least 50 percent, as determined by TMEC, older than 18 years of age are eligible to receive monthly financial assistance. The amount depends on the degree of disability, the type of disability pension they receive and on the need for assistance by others. To receive this benefit, a person with a disability needs to undergo an individual needs assessment process, although it bears no impact on eligibility. In 2020, the level of this benefit was: 1. For a degree of disability 50-70.99 percent: 7 percent of the poverty line172 (25.41 BGN), 2. For a degree of disability 71-90 percent: 15 percent of the poverty line (54.45 BGN), 3. For a degree of disability >90 percent: 25 percent of the poverty line (90.75 BGN), 4. For a degree of disability >90 percent + care by others + disability pension due to general illness /work accident/ occupational illness: 30 percent of the poverty line (108.90 BGN), 5. For a degree of disability above 90 percent + care by others + social disability pension: 57 percent of the poverty line (206.91 BGN). Data in Table 5.8 presents the recipients and related public spending on this benefit. Overall, in 2020, about 90.0 percent of all adults with disability received this support. Table 5.8: Monthly financial assistance to persons with disabilities – recipients per month and annual expenditures 2019 Recipients Expenditure Average per (average per (total, BGN) month (BGN) month) 50-70.99 percent degree of disability 173,500 63,388,920 30.4 71-90 percent degree of disability 299,942 194,659,139 54.1 >90 percent degree of disability without entitlement 123,402 120,212,377 81.4 to support by others >90 percent degree of disability entitled to support by 26,279 28,740,393 92.1 others and with disability pension due to general illness or an occupational illness/work accident >90 percent degree of disability with entitlement to 12,971 28,740,393 184.7 support by others and with social pension for disability Total number 636,093 437,506,053 57.3 Source: Social Assistance Agency 172 The poverty line is determined annually by the Council of Ministers following a formally adopted methodology. For 2020, the poverty line was 363 BGN. 107 (vi) Targeted financial support Children and adults with disabilities are eligible for targeted financial support, which is provided to: 1. persons with reduced mobility for purchasing a personal vehicle; 2. persons in wheelchairs for a living space adaptation; 3. persons with disabilities for rehabilitation and balneotherapy services; 4. persons with disabilities living alone and single parents with children with disabilities renting public housing. Each benefit, in addition to a TMEC certificate and an individual needs assessment, features specific eligibility requirements. For example, to access a reimbursement for a vehicle purchase or a house adaptation cost, the applicants should have degree of disability above 90 percent and their per capita household monthly income in the last 12 months should be equal to or below the poverty line. Table 5.9: Targeted financial support to persons with disabilities - recipients and expenditure 2017-2019) 2017 2018 2019 Expenditur Expenditur Expenditur Recipients Recipients Recipients es BGN es BGN es BGN Personal vehicle purchase 3 3,600 5 6,000 6 8,712 Living space adaptation 0 0 7 4,200 28 20,328 Rehabilitation and 5,733 1,117,935 5,899 1,327,275 4,982 1,446,773 balneotherapy services Rent of public housing 974 369,960 959 385,958 1,035 440,450 Total number 6,710 1,491,495 6,870 1,727,460 6,051 3,643,723 Source: Social Assistance Agency, annual reports. As data in Table 5.9 suggests, the number of recipients of targeted financial support is small. There could be many reasons for that, including low awareness about the importance of house adaptation, a low level of support (e.g., 35 BGN per month of rental subsidy in 2019), etc. (vii) Targeted support for assistive technology, devices, facilities, and medical equipment Support to access assistive technology, devices, facilities, and medical equipment (“technical aids”) is regulated by the Persons with Disabilities Act173 and it covers expenses for production, purchase, or repair of technical aids. Currently, to receive technical aids, a person should submit to SAA a decision issued by either TMECs or MACs (for temporary disability – sick leave174) that she/he needs technical aid(s) and should have a completed individual needs assessment. Eligible devices must be on approved list with fixed prices175 and their suppliers must be registered. Administrative procedure to access technical aids is as follows. After the individual needs assessment has been completed, a person or her/his representative must also submit the following documents to a relevant municipal SAA office: (i) a pro forma invoice (preliminary invoice) for the aid from a 173 Art. 72-73 and others. Amendments to PDA (December 4, 2020) transferred the provision of assistive technology, devices, facilities, and medical equipment to the National Health Insurance Fund and the Ministry of Health and its relevant agencies from MLSP and its Agency for Persons with Disabilities, to be effective as of January 1, 2022. 174 See chapters 3 and 4 of this Report. 175 The list with approved assistive technology, devices, facilities, and medical equipment is part of the Regulation on the Implementation of the Persons with Disability Act. https://www.lex.bg/bg/laws/ldoc/2137192229 108 registered supplier and (ii) a document from a supplier, certifying that it is properly registered.176 The SAA’s municipal office should issue an order within 10 working days. After having received the order and a handover protocol, a person submits these to the supplier, receives the aid and both parties sign the handover protocol. The aids supplier should submit a request for reimbursement to the municipal SAA office that has issued the order, attaching to it: an invoice, original order, and the signed handover protocol, as well as a proof that the device falls within the approved list. Table 5.10 presents data on persons with disabilities who were provided technical aids in 2017-2019. Table 5.10: Targeted support for technology, devices, facilities and medical equipment and expenditure 2017-2019 – recipients and expenditure 2017 2018 2019 Recipients Expenditure Recipients Expenditure Recipients Expenditure BGN BGN BGN Targeted support for technology and 10,476 52,346,150 8,075 38,064,137 6,937 32,605,079 devices Source: Social Assistance Agency. Annual reports 2017-2019. (viii) Targeted support for yearly vignette A person with a degree of disability of 50 percent or above, or a person /family raising a child with disabilities up to 18 years of age (up to their graduation from high school but not above 20 years of age) have a right to a free annual road vignette for one car, if the requirements concerning the vehicle specification parameters are met.177 About one third of persons with disabilities in Bulgaria is benefiting from the free vignette and the number has steadily been growing. Between 2017 and 2019 it has grown from 218,835 persons to 237,392 persons (8.5 percent). The use of benefits depends on the awareness about the benefit existence and on the car ownership by persons with disabilities. The total reported expenditure on free vignette in 2019 was 23.0 million BGN, or 99 BGN per beneficiary. (ix) Other benefits Persons with disabilities have the right to use some general administration and other public services free of charge or at discounted fees, and to also benefit from social programs available to all Bulgarians. They include: • Fee discount when applying for identity documents (ID card, passport and driving license). • Exemption from fee payment/co-pay for medical examination by general practitioner and hospital treatment. • Two free rail journeys per year inside the country (also applies to accompanying persons, personal assistants, and guide dogs). • Guaranteed minimum income. This is a monthly means tested social assistance benefit available to all Bulgarian citizens/families whose per capita income is below a certain 176 This implies that the person not only must have a need certified by TMEC/NMEC and verified by SAA in the individual needs assessment, but that she/he has identified a legitimate (registered) supplier and have obtained from it a preliminary invoice and a protocol of its registration. 177 Article 10 of the Roads Traffic Law. 109 differentiated guaranteed minimum income threshold. Eligibility requirements178 such as movable/immovable property and employment status applicable to general population are not applicable for persons with disabilities. In addition, persons with disabilities are exempted from participating in community work. For persons with disabilities who qualify, the benefit is as follows: for a person with permanently reduced work capacity >50 percent, 100 per cent of the GMI; for a person with permanently reduced work capacity >70 percent, 125 per cent of the GMI. • Targeted allowance for heating.179 Entitled to this allowance are persons and families whose average monthly income for the previous 6 months before the month of submission of the application is lower or equal to the differentiated income for heating and meet conditions under Art. 10 and 11 of the Regulations for Implementation of the Social Assistance Act. For persons with disabilities the amount of assistance, depends on the degree of disability. • Students with disabilities. Students with sensory disabilities and others with permanent disabilities and reduced work capacity >70% are entitled to special benefits provided for in the regulation on higher education.180 • Health insurance is covered by the state for veterans and war victims who do not have health insurance, persons with disabilities, persons who receive a disability pension, as well as parents, adoptive parents, spouses or one of the parents who takes care of a disabled person with a disability over 90% in need of assistance for daily routine.181 • Discounted (free for state owned) admission to museums and galleries.182 • Work related:183 Persons with disabilities (>50%) with labor contracts have the right to additional paid leave;184 and, in case of dismissal, an approval from the National Labor Inspection185 is required. • Municipal benefits: Persons with disabilities are entitled to several benefits at municipal level. Those are applicable in municipalities by local decisions of the municipal council and municipal administration, and they are the following: o right to a free of charge parking and guaranteed access to parking places, o reduced price for the use of public transport, o additional points when applying for public municipal housing, o guaranteed access to a kindergarten for children with disabilities. Furthermore, within their authority, municipalities ensure accessible built environment in kindergartens and schools, accessible public transport by adapting the existing public transport and commissioning vehicles technically adapted for use by persons with disabilities, special transport services for people with disabilities. 178 To qualify for the GMI program, general population needs to fulfil several eligibility criteria related to income, size of the person’s dwelling, property ownership, he/she should be registered as the unemployed with the Labor Office at least 6 months before the submission of the application-declaration for social assistance and not to have rejected offered jobs or education/training, etc. The requirements are relaxed in the case of persons with reduced work capacity. 179 Аrt. 10 of the Regulation on the Implementation of the Social Assistance Act, https://www.lex.bg/laws/ldoc/- 13038592; Regulation of MLSP № РД-07-5 from 16.05.2008 for the conditions and order for awarding the targeted support for heating; https://www.lex.bg/laws/ldoc/2135588875. 180 Art. 70, paragraph 2 of the Higher Education Act. 181 Art 40, paragraph 2 of the Health Insurance Act; https://www.nssi.bg/images/bg/legislation/laws/ZZO.pdf. 182 Art. 187 of the Cultural Heritage Act, https://www.lex.bg/laws/ldoc/2135623662. 183 The Labor Code, https://www.noi.bg/images/bg/legislation/Codes/KT.pdf. 184 The Labor Code Art. 333, par. 2. 185 Ibid. 110 No data on beneficiaries and public expenditure on these programs is available. (x) Support for parents and relatives of persons with disabilities Parents and close relatives who take care of persons with disabilities are eligible for the following: (i) parents of children with disabilities under 16 years of age are exempt from paying mandatory social security contributions,186 and (ii) parents of children with disabilities and care givers of persons with disabilities have the right to health insurance if they are unemployed and are not ensured under other arrangements. Eligibility criteria include: i) being a parent of a person with disability/ reduced work capacity with a level of disability of 50 percent or more and ii) providing unemployment declaration monthly to the local SAA office. (xi) Social services for persons with disability The Social Services Act (SSA)187 defines social services for persons with disabilities as actions to prevent and/or overcome their social exclusion, exercise their rights, and improve their quality of life. The SSA came into force in June 2020 and is expected to introduce substantial changes in social services as of 2022. Currently social services for persons with disabilities are organized according to the Social Protection Act (SPA). Since 2020, a definition of social services in the Social SPA differentiates community based social services and specialized institutions.188 The new definition of social services in SSA excludes specialized institutions from the list of social services and there is a plan to close all specialized institutions up to 2035. SSA defines two groups of social services: i) social services targeted to the general population189 and ii) specialized social services190 for people who need specialized support (e.g., children and persons with disabilities in need of long-term support). Article 14 specifies the following target groups: (1) Depending on the age of users, social services may be for children and for adults; (2) Depending on the specific needs of users, social services may be for all children, children at risk as defined by the Child Protection Act, parents, adoptive parents, persons caring for children, candidates for adoptive parents and candidates for foster families, children and adults with disabilities, adults in a crisis or with a need to overcome the consequences of such a situation; older adults (over working age) and persons who take care of adults. SSA lists 15 kinds of social services, most of which are applicable to persons with disabilities. Currently, still following the SPA rules, social services centers are defined as centers combining different support activities.191 186 Art.70a, paragraph 2, point 5 for a parent of children up to 16 years of age, and point 6 for a parent (mother or father), husband/wife, grandfather/ grandmother of a person with disabilities with 50 percent disability and assigned assistance by others, Social Secure Code. https://www.lex.bg/laws/ldoc/1597824512/ 187 https://www.lex.bg/bg/laws/ldoc/2137191914 188 Specialized institutions provide residential placement to children and adults with disabilities or older adults. 189 According to SSA, public social services include: 1. provision of short term (up to 2 months) services to inform, consult and train and develop skills for the realization of social rights; and 2. mobile preventive community work. 190 Specialized social services are provided: 1. when certain risks to life, health, quality of life or development of a person materialize; and 2. when there is a specific individual need. 191 Data about the provision social services is according to the current definitions and practice and, thus, differ from the social services description according to the new legislation whose implementation is stipulated for January 1, 2022. 111 Targeted services for children with disabilities are envisaged to include information and consultation,192 therapy, rehabilitation, skills training,193 day care and residential care. To access services, a disability degree of at least 50 percent is required. Parents of children with disabilities will be eligible to information and consultation, advocacy, mediation, respite care and skills development social services. Currently, social services provided to children with disabilities are delivered by Day Care Centers, Centers for Social Rehabilitation and Integration, and Family Type Residential Care Centers. Data on the use of social services signal relatively low use of services (Table 5.11), most likely determined by low supply and limited menu of services. In 2019, only 6,418 children or about 25.0 percent of all children with disabilities used of social services (one fourth of which were placed in residential care). Table 5.11: Services for children with disabilities, users 2017 -2019 2017 2018 2019 Users Users Users Residential care 1,650 1,546 1,518 Day care services with included therapy and 2,625 2,728 2,845 rehabilitation Therapy and rehabilitation services 1,927 2,060 2,055 Total 6,202 6,334 6,418 Source: Social Assistance Agency According to the SSA, social services for adults with disabilities (with at least 50 percent disability certified by TMEC and over 18 years of age) include specific services (day care, work skills development, residential care) and social services targeted to general population including persons with disabilities (information and consultations, therapy, and rehabilitation). According to the current situation as described in the old act (SPA), social services for adults are as follows: day care centers, centers for rehabilitation and integration of adults, sheltered living, and family type residential care centers. Specialized institutions providing institutionalized care are included as well - still an important option for many persons with disabilities without caregivers. Data presented in Table 5.12 indicate a small number of users of social services for persons with disabilities, which as in the case of children, is most likely a consequence of the services’ low supply and limited menu. 192 Information and counseling services should provide a possibility for a child with disability to participate in activities that enable him/her to learn and understand the problems and challenges she/he faces and to explore and possible solutions and actions to overcome them 193 Preparing children and adults to acquire skills for independent living, independent management of problems and challenges. 112 Table 5.12: Social services for adults with disabilities, users 2017 -2019 2017 2018 2019 Users Users Users Family-type residential placement center - for all 1,269 1,694 1,852 types of disabilities Sheltered housing (all types of disabilities) 1,223 1,010 981 Daycare center for adults with disabilities 1,944 2,021 2,096 Center for social rehabilitation and integration 3,567 4,242 5,019 for adults with disabilities Specialized institutions (residential institutions) 6,118 5,855 5,341 for persons with disabilities194 TOTAL 14,121 14,822 15,289 Source: Social Assistance Agency, Decisions of Council of Ministers No. 920/02.11.2016, No. 667/01.11.2017, No. 776/30.10.2018 Provision of social services is delegated to municipalities as the “state delegated activity”. Municipalities are also responsible for analyzing, planning, and controlling the quality of services and for carrying out a preliminary assessment195 for people with disabilities or other persons in need requesting specialized social services. The delegation status ensures state funding for the social services provision196 up to the approved maximum number of users according to the National Map of Social Services.197 Municipalities are responsible for capital cost. They can contract out service provision to licensed private service providers, following the state public procurement rules.198 To qualify for social services, children with disabilities must have a degree of disability >50 percent certified by TMEC. They also need to have completed a “preliminary needs assessment”, stipulated under the Social Services Act, prepared by a municipal body, or completed individual needs assessment under the PDA, prepared by a SAA municipal office. The need for services must be identified and stated in the assessment report. Services can only be used in the municipality where the current address of the family/parent is registered. It is possible to use services in another municipality, but only if there is an inter-municipal agreement. To place a child with or without disability into residential care, a court decision is needed. The exceptions are residential care placement for up to 30 days per year of children with a degree of disability >50 percent in need of constant medical supervision and care, and a placement of children up to 3 years of age with a degree of disability >50 percent in need of constant medical supervision and support. Eligibility criteria are largely the same for adults with disabilities, with few differences: (i) preliminary assessment in the case of adults with disabilities under full or partial guardianship is conducted by the SAA office, not local municipality, because municipality is responsible for the implementation of guardianship measures; (ii) to place a person with disabilities under guardianship into residential care or specialized institutions, a court decision is needed; (iii) residential care placement should be considered only after all other care options have been exhausted. 194 Home for adults with intellectual disabilities, home for adults with mental disorders, home for adults with physical disorders, home for adults with sensory disorders, home for adults with dementia. 195 Preliminarily assessment is the entry procedure for persons with disabilities to access social services. 196 Art. 45. Ibid. 197 Art. 43. Ibid. 198 Art. 63. Ibid. 113 Administrative process to access services in the case of children with disabilities is as follows: • Stage 1: Obtain TMEC decision of >50 percent disability. • Stage 2: Request services and an assessment of needs - there are three options: o Option 1: The parent applies directly to the service provider and the child starts using the service for a period of two months, after which the parent must request the extension. o Option 2: The parent requests a service at the municipal office and provides the TMEC decision. A preliminary assessment is conducted within 20 days. The parent receives information about approved services and is directed to a specific type of service. o Option 3: The parent requests an individual needs assessment at the municipal SAA office, completes the self-assessment and provides the TMEC decision. Within 30 days he/she receives the assessment conclusion with approved social service(s). • Stage 3: Access services. After the decision with prescribed services is received, the family approaches a service provider. Three options are possible: (i) acceptance; (ii) waitlisting and (iii) rejection. The process is the same for adults with disabilities. Overall, social services are underdeveloped in Bulgaria, with uneven geographical coverage. Low numbers of users suggest limited supply and menu of services. While Bulgaria has undertaken lots of efforts to deinstitutionalize care, residential care institutions still play an important role. Community based care services, and early intervention and preventive services are in their infancy. The menu of services is limited. There are municipalities in the country where there are no social services, as well as municipalities where only one type of social services is provided. Only few municipalities, mostly in large urban centers, provide a wider range of social services. Some groups of persons with disabilities are especially disadvantaged – persons with psychiatric disorders, persons with severe intellectual disabilities and people with dementia.199 The new Social Services Act sets out an ambitious agenda for the development of social services, but it needs time, resources and persistence before significant results will have been achieved. In any case, given a critical importance of social services for improving functioning of persons with disabilities, the development of these services ought to be a priority for authorities in Bulgaria. (xii) Assistants’ support for persons with disabilities During the last 10 years, assistants’ services200 to persons with disabilities have been provided by the National program for assistants for persons with disabilities (funded through the National Employment Plan as an employment support measure under the Employment Promotion Act (EPA), and under projects funded through the Operational Programs.201 The SSA regulates services of an assistant provided at home or outside of it for: (i) self-care; (ii) movement and transportation; (iii) change of the body position; (iv) housekeeping and other daily activities; (v) communication (as defined by SSA). This program is implemented as of 2022. The Employment Promotion Act regulates assistants’ services to persons with disabilities as a program for subsidized employment of assistants to persons with disabilities. A program called “National program 199 Action plan for the period 2018 – 2021 for implementation of the National strategy for long-term care. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjl7aG L7cvuAhVpmYsKHUuMA6MQFjABegQIARAC&url=http%3A%2F%2Fwww.strategy.bg%2FFileHandler.ashx%3Ffil eId%3D17626&usg=AOvVaw33koPmqtlO78e62mygGlG- 200 The new SSA recognizes assistants’ support as a type of social services. 201 Operational programs are national thematically structured programs with EU funding and national co- funding. 114 for assistants for persons with disabilities” provides “personal assistant” and “assistant tutor” to persons with disabilities. Services are provided for up to four hours a day and include: food delivery and preparation and help with eating, shopping, assistance with personal hygiene: dressing/undressing, washing, bathing, hair combing, getting into a wheelchair, etc., housekeeping and other tasks such as lighting a fire, chopping and carrying wood, shoveling snow, etc. The number of assistants for the year is planned in the “National Employment Plan”. In 2020, the national program “Providing Support at Home” was implemented. It provided housekeeping assistants for persons with disabilities with a degree of disability between 80 percent and 89.99 percent with assigned support from other people, as well as for persons with disabilities of retirement age not able to self-care. Based on the National Employment Plan the assistants’ support is organized by state institutions and municipalities. The recruitment of assistants is implemented by local offices of Employment Agency (EA), the applications and provision of the service is organized by municipalities and the verification of eligibility is performed by municipal SAA offices. The eligibility requirements are as follows: • TMEC certified disability >50 percent and its conclusion that a person needs assistance from other people. • Persons in retirement age, incapable of self-care do not need a TMEC decision; the practice is that a decision of a medical advisory committee (MAC) is sufficient. • A conclusion from “preliminarily assessment” that she/he needs services of an assistant. This assessment is organized by a local authority. The same authority acts as service provider. • In addition, to be eligible for assistants’ services under the employment program, the following is needed too: (i) the person with disability’s income in the month proceeding the application is lower than 5 times the guaranteed minimum income,202 or up to 375 BGN per family member; (ii) the person cannot be registered as a business-owner; (iii) the person cannot have other sources of income (property, etc.). The eligibility for this program is checked by the municipality as provider. The administrative procedure to access the service is as follows: • The person, or her/his legal representative, submits a request form to the municipal administration to be included in the program. • The municipality forwards the information to the relevant local office of the SAA, which verifies the information and must decide within ten days if the person will be included in the program. • After a confirmation that the person fulfills the requirements, the municipal administration prepares an individual assessment203 and determines the number of hours of assistant’s services. • The municipality keeps a list of requests; in case the demand is higher than capacity to meet it, first come – first served principle applies. • In parallel with the applicant assessment, the municipal administration requests from the Employment Office to direct the needed number of job seekers to serve as assistants. • The municipality signs short-term contracts with the assistants. 202 The guaranteed minimal income is determined by the Council of Ministers; it has been 75 BGN since 2017. 203 Note that this assessment is separate from the individual needs assessment conducted by SAA. 115 The number of users benefiting from assistant services through the National Program has been low due to limited funding. Substantially bigger is the number of users through programs funded with additional budget based on decisions of the Council of Ministers (DCM) – see Table 5.13. Table 5.13: Assistants to persons with disabilities, beneficiaries and expenditure 2017-2019 2017 2018 2019 Annual Annual Annual Users expenditure Users expenditure Users expenditure in BGN in BGN in BGN National employment program "Assistants to 2,450 8,912,000 2,131,00 6,763,939 1,967 7,558,200 persons with disabilities" DCM № 344/21.12.2018 and DMC № 23,272 75,727,970 180/18.07.2019 DMC № 332/ 22.12.2017 22,513 72,924,199 DMC № 137/ 05.07.2017 13,520 15,700,000 Source: National Employment Plan for 2019 and 2018 and Social Assistance Agency. Note: Data on users are monthly averages. Expenditure data is annual. DCM denoted “decision of the Council of Ministers”. (xiii) Personal assistance to persons with disabilities Personal assistance is regulated by the Personal Assistance Act (PAA)204 as a support mechanism for the users for their full participation in society, to carry out activities corresponding to personal, domestic, or social needs and to overcome the obstacles to functional limitations. It has been implemented since September 2019. Thus far, in most cases, this assistant is a spouse or a close relative of a person with a disability.205 The personal assistance mechanism allows parents and relatives who take care of persons with disabilities to receive remuneration for this work under a labor contract. This labor contract ensures income and social insurance. Only in cases when the choice is not made, a municipality as a provider should propose a personal assistant. The PAA stipulates that anyone (employed, unemployed, self-employed), pensioner or a person with a disability may be an assistant. This differs, for instance, from the programs under the National Employment Action Plan, which requires that only persons registered as unemployed can be employed as home assistants. A person requesting personal assistant services need to undergo an individual needs assessment following a uniform methodology. The personal assistance is offered for a period that depends on the assessed degree of dependance – from several times a month to 8 hours a day (see Chapter 4). Eligible to receive services of the personal assistant are persons with a permanent disability with an established type and degree of permanently reduced work capacity with need for assistance by 204 Article 3. https://www.lex.bg/bg/laws/ldoc/2137189250. 205 The motivation for this law was to provide a mechanism through which, spouses, children and other informal care and support givers to persons with disabilities will be compensated. 116 another person; children with type and degree of disability that is 90 or over 90 percent or a degree of permanently reduced work capacity without established need for assistance by another person. Persons with disabilities who are awarded this benefit have some of their other benefits in cash reduced: (i) for children whose families receive a family allowance for children with disability, by up to 380 BGN. The exact deduction depends on the allocated number of hours of support; (ii) for adults receiving pension and a supplement for assistance from others, the amount of the supplement is deducted. To receive personal assistance, a person undergo a comprehensive individual needs assessment (i.e. PDA INA – see Chapter 4). While the assessment per se does not determine the right to personal assistance, as that right depends on the TMEC conclusion about the need for assistance by others, it is used to determine the level of dependence and the hours of support the applicant would receive. The individual assessment is conducted by a local SAA office, according to the person’s current address. (See Chapter 4 for details). Once the PDA INA is completed and the level of dependance and the number of personal assistance hours determined, the person with disability contacts the local administration, submits the issued “direction for personal assistance” and provides a name of the proposed personal assistant, as well as a name of an alternative personal assistant. If he/she cannot indicate a specific person, the municipality suggests a personal assistant. The chosen personal assistant submits documents required for the appointment and formally starts the position after signing the contract. PAA stipulates an hourly wage of 140 percent of the minimum hourly wage. Social and health insurance are also provided on the account of the employer (municipality). There are four levels of this benefit: (i) for the first degree of dependence – up to 15 hours per month; (ii) for the second degree of dependence – up to 42 hours per month; (iii) for the third degree of dependence – up to 84 hours per month; and (iv) for the fourth degree of dependence – up to 168 hours per month. Table 5.14: Personal assistance to persons with disabilities – users and expenditure 1.04.2019 -31.12.2019 1.01.2020 - 31.10.2020 Users Expenditure in BGN Users Expenditure in BGN Personal assistance 27,923 23,054,697 19,401 50,852,531 Source: Social Assistance Agency Table 5.14 shows data on beneficiaries of personal assistants and related public expenditures. During the first 10 months of 2020, there were 19.4 thousand users of personal assistance. On average, monthly expenditure per assistant was 260 BGN. This very important program that reimburses caregivers to persons with disabilities in need of assistance by others, where assistants can be spouses and other close family members, and where a formal employment relationship between the caregiver and the relevant municipality is signed is in its infancy. It is early to make any conclusions about its design, implementation, and impact. A close monitoring of the program and an impact assessment are recommended. 5.4 Key messages Bulgaria features an impressive range of publicly financed social protection and other programs specifically designed to support persons with disabilities.206 Benefits range from cash transfers to technical aids, to rehabilitation and care services, to personal assistance, to residential placement, as 206 Health, including medical rehabilitation and education services are not included in this report. Labor market interventions to support employment of persons with disabilities are discussed in Chapter 6. 117 well as benefits such as tax reduction, free/subsidized transportation, discounted entry into museums, etc. Support is provided both by the national government and municipalities. Support to persons with disabilities is regulated by various laws and associated regulations of the Council of Ministers and other relevant government bodies. Very important changes to the disability benefits system were introduced in 2019 with the Persons with Disabilities Act, Social Services Act, and Personal Assistance Act and associated bylaws. Particularly important were the introduction of a comprehensive individual needs assessment and a personal assistance program, which compensates (mostly) family members taking care of persons with disabilities in the form of formal employment. Different programs require different degree of disability, with some available only to persons with a degree of disability >90.0 percent. For several benefits, such as services of an assistant or a disability pension supplement for assistance by others, or technical aids, the TMECS’ decision specifying the need for a benefit is needed as well. The coverage by disability support interventions seems high. While data on support measures included in this chapter may not be complete, based on information presented, there were in 2019 about 1.7 millions of benefit “units” provided to persons with disabilities or about 2.3 per person with disabilities, including children. In 2019, among the 753,204 persons with disabilities, 513,435 were receiving a disability pension, 73,637 received a supplement to a disability pension for assistance by others, 636,093 received monthly financial assistance, 237,392 used free annual road toll vignette and all children with disabilities were covered by monthly financial allowance. While no data is available on distribution of support measures and whether and how many persons with disabilities do not receive any support, available data suggest a very high (complete) coverage by at least one support measure. The level of various cash benefits varies significantly indicating insufficient synchronization across the system. Given that persons with disabilities can and do receive several cash benefits, it is impotent to ensure consistency in setting their level and ensure their synchronization to avoid adverse incentives and allow them to achieve their objectives. Some monetary benefits appear low. Tracking who receives what is important, first and foremost for the well-being of persons with disabilities, but also for the efficiency and effectiveness of the system. A database of persons with disabilities, currently with the Agency for Persons with Disabilities provides an excellent tool for collation of such information and so does a data base that is compiled from the comprehensive individual needs assessment by the Social Assistance Agency. Public expenditure on disability support measures is significant. Public expenditure, as available data show is at about 2.4 percent of GDP in 2019, inclusive of disability pensions, (this is double the 1.2 percent reported by Eurostat, which may be due to different methodology). The expenditure data is not complete, as the cost to the budget of the health insurance coverage, reduced/no co-pay for health services, social care services, employment support measures, medical rehabilitation, municipal benefits, forgone budget revenues due to income tax base reduction, etc. is not included. Development of social services for persons with disability has been lagging. In the structure of support measures to persons with disabilities, monetary measures dominate. Social services are underdeveloped in Bulgaria, with uneven geographical coverage. Low numbers of users suggest limited supply and menu of services. While Bulgaria has undertaken lots of efforts to deinstitutionalize care, residential care institutions still play an important role. Community based care services, and early intervention and preventive services are in their infancy. There are municipalities in the country where there are no social services, as well as municipalities where there is only one type of social service. Only few municipalities, mostly in large urban centers, provide a wider range of social services. Some groups of persons with disabilities are especially disadvantaged – persons with psychiatric disorders, persons with severe intellectual disabilities and people with dementia. The new Social Services Act 118 sets out an ambitious agenda for the development of social services, but it needs time, resources and persistence before significant results will have been achieved. In any case, given a critical importance of social services for improving functioning of persons with disabilities, the development of these services ought to be a priority for authorities in Bulgaria. Administrative process to acquire benefits seems demanding. A review of programs to support persons with disabilities shows that persons with disabilities are required to apply for each disability benefit separately (a demand-based approach), even in cases when several benefits are administered by one agency. This supposes that they know which benefits are available and how to access them (for technical aids and rehab services people are asked to find providers as well), which is mostly not the case. While each implementing agency is mandated to provide pertinent information on its website, there is no integrated information available in one place and no single entry through the government portal to access it. Often, persons with disabilities are asked to submit same documents repeatedly, despite the existence of several management information systems that are supposed to contain a comprehensive information on each person with disabilities and can formally exchange them. Furthermore, currently, there is a complex, individual needs assessment (PDA INA), “preliminary” needs assessment (for services) and needs assessment (by social services providers). This is probably the consequence of a fast-changing system, where legal provisions change frequently, while administrative processes take time to adjust. Based on the above, we recommend: Better information on programs available to persons with disabilities is needed . An information booklet with all programs, including their eligibility requirements and how and where to apply for them should be available in regularly updated electronic and printed formats. The printed booklet should be handed to each person applying to MAC/TMEC/NMEC. Ideally, this information should be compiled and maintained by the government body responsible for the coordination of disability policy as it requires inputs from various agencies at the national, regional, and local levels of government. In addition, organizations of persons with disabilities, social security branches, municipalities, MLSP and other relevant bodies and organizations can organize seminars and run information campaigns. The objective is to provide up to date and comprehensive information to persons with disabilities and their families. Integrated management information system. An integrated management information system is needed to enable automatic information flow between various relevant agencies, including from MACs to TMECs/NMEC; from TMECs/NMEC to SSI and SAA; from SAA to government departments implementing various programs (as a referral together with the needs assessment and an action plan), etc. In this way, the process will be much less onerous to persons with disabilities, information flow smooth and decision making easier. There should be no need to for persons with disabilities to submit the same documents repeatedly – most of them are already stored in the information system of the regional health files and should be available to officers in other relevant agencies while performing their official duties and following data privacy protection rules. Make administrative processes for acquiring disability benefits smoother, better integrated and less demanding: The linkages between disability certification (TMEC/NMEC), a complex, individual needs assessment (SAA), an action plan development (should be done by local offices of SAA in a multidisciplinary fashion), referrals (by SAA) and access to services (persons with disabilities, service providers) ought to be much better integrated. In that, the PDA individual needs assessment should play a critical role, including in matching and linking individuals and benefits/services available to them. There should be no multiple needs assessments. 119 Improve information on each person with disability. The database on persons with disabilities, currently maintained by the Agency for People with Disabilities of MLSP, which contains extensive information on everyone with disability in Bulgaria, should be able to also collate information on benefits they receive. Data should be available to program administrators in carrying out their official duties, to policy makers, and, in anonymized format, to the public for research. Such data is needed for evidence-based disability policy making and for monitoring of its implementation. Another excellent source of information is the data base of the Social Assistance Agency built inter alia on data collected through the complex individual needs assessment. Prioritize development of community based social care services for persons with disabilities. Social care services development has lagged, although they are critical for optimizing functioning of persons with disabilities to ensure their full participation in life activities. Impact on well-being of persons with disabilities. Analyze impact on public policies and related public spending on persons with disabilities. This could only be done through a living conditions survey and/or by the World Health Organization’s Model Disability Survey (MDS). Conducting MDS would provide an excellent baseline on well-being of persons with disabilities in Bulgaria. 120 Chapter 6: Labor market inclusion of persons with disabilities In this chapter we discuss the situation of labor market inclusion of persons with disabilities in Bulgaria. Low labor force participation of persons with disabilities is almost a universal phenomenon.207 Empirical evidence from developed countries with established social security systems shows that most of the working age persons leave employment due to disability and transition to a disability pension (irrespective of whether they can work and receive a disability pension at the same time, which is the case in Bulgaria). They rarely return to the labor market. Furthermore, persons with disabilities are a very diverse group. From the labor force participation perspective, there are three groups: (1) Working age adults with disabilities since childhood. Their labor market prospects depend to a very significant degree on education and skills development opportunities they had had before they reached the working age. In many cases, particularly with intellectual disabilities, they are difficult to place in the labor market. (2) Working age adults who have acquired disability during adulthood. Majority of persons with disabilities belong to this group. Most of them are active in the labor market at the time they acquire disability and leave employment due to a reduced work capacity, even when it is at moderate levels. They are the group that has the highest potential to stay in the labor market. (3) Older people – above working age (65 in Bulgaria) with disabilities who have retired but can and wish to continue working. Each group has different potential concerning labor market inclusion and each requires a specific set of interventions to encourage and support it. 6.1. Statistics on labor market participation of persons with disabilities According to the National Statistics Institute (NSI) Labor Force Survey (LFS),208 in 2019 (Table 6.1), there were around 227,100 working age persons with disabilities corresponding to 5.08 percent of the total estimated working age population. In 2019, there were 53,800 persons with disabilities in the labor force (employed plus unemployed) or 24.0 percent, compared to 73.0 percent for the entire working age population. The 2019 labor force participation rate of persons with disabilities was the highest observed during the 2014-2019 period. Contributing factors include a 15.0 percent decrease in the LFS estimated working age population with disabilities: from 268,300 in 2015 to 227,100 in 2019 and a decline in the LFS estimated number of unemployed persons with disabilities that in the same period fell by 60.0 percent (from 9,900 in 2015 to 4,000 persons in 2019). The LFS data show a low rate of employment among working age persons with disabilities: 21.9 percent in 2019, an increase from 19.6 percent from 2015 (although from a low base of 18.4 percent). The employment rate among all LFS estimated working age population was 70.1 percent in 2019 – an 11.3 percent increase since 2015. The composition of employment shows that significant part of employment among persons with disabilities – almost one fifth - is dependent on public support. In 2019, the National Employment Agency (NEA) financed employment of 7,900 persons with disabilities or 15.9 percent of all employed persons with disabilities. With, 1,130 employed persons with disabilities in 221 specialized enterprises, the public employment support to persons with disabilities raises to 18 percent of all employed persons with disabilities. The 2019 LFS estimates the unemployment rate among persons with disabilities at 7.4 percent, reflecting a small number of unemployed persons with disabilities seeking jobs. The rate has declined 207 See www.oecd.org. For example: Disability, Work, and Inclusion in Ireland, 2021, Sickness, Disability and Work: Breaking the Barriers. A Synthesis of Findings across OECD Countries. 2010. Sick on the Job? Myths and Realities about Mental Health and Work. 2011, etc. 208 LFS is conducted by the National Statistical Office. The data disaggregated by persons with disabilities were requested and granted by NSI. 121 from 17.0 percent in 2015. This trend is corroborated by the National Employment Agency (NEA) data, although NEA records show much higher numbers of registered unemployed persons with disabilities (16,923 in 2015 and 11,873 in 2019) compared to LFS data209 (Table 6.1). A decline in the unemployment rate among persons with disabilities in the last 5 years is in line with the general decrease in unemployment due to stable economic growth and labor market shortages.210 High inactivity rate is the main distinctive characteristic of the labor market participation of working age persons with disabilities in Bulgaria. In 2019, the inactivity rate was 76 percent compared to 27 percent for general working age population. Although there has been a small decrease in inactivity rate by 1.7 percentage points compared to 2015, the pace is more than twice slower than that among the general working age population (4 percentage points). Thus, even in years of the fast-developing labor market211 this specific group does not take full advantage of the economic growth, which stood at 3.5 percent average for the period 2016-2019.212 In the same context, LFS data show that 68.5 percent of young persons with disabilities of age between 15 and 29 are neither in employment, nor in education nor in training (NEET), while the NEET rate in general population was 16.7 percent. While the NEET rate for young persons with disabilities has not changed compared to 2015, the NEET rate in the general respective population dropped by almost 6 percentage points compared to 2015 when it stood at 22.2 percent. The above-presented data reflect many challenges faced by persons with disabilities in the labor market. The situation is particularly difficult among working age persons with disabilities since childhood. While empirical evidence is mostly lacking, anecdotal evidence suggests that they often lack education, skills, and experience; they face prejudice, social isolation, poor information, lack of motivation to seek employment, low investment in supported employment, insufficiently adjusted work environment and other barriers to labor market inclusion. 209 It is a common occurrence that administrative and survey-based data differ, particularly in the case of smaller population groups that are difficult to capture in the sample frame. For instance, LFS 2019 estimates the number of persons with disabilities 15 years of age and older at 443,000 (vs. 725,000 based on administrative data, indicating that LFS captures 61.0 percent of persons with disabilities. The discrepancy is an issue that should be addressed by the NSI. 210 These observations do not consider the 2020 COVID-19 pandemic situation. 211 The unemployment rate among of general population (15-64 years old) dropped from 13% in 2012 to 4.3% in 2019 - (NSI LFS data; see also Table 6.1) https://www.nsi.bg/bg/content/4011/безработни-лица-и- коефициенти-на-безработица-национално-ниво-статистически-райони 212 https://www.bnb.bg/Statistics/StMacroeconomicIndicators/index.htm 122 Table 6.1: Bulgaria - labor force and activity rates for persons of 15 -64 years of age 2015 2016 2017 2018 2019 People People People Labor Status People with People with Total* Total with Total with Total with Total disabilities disabilities disabilities disabilities disabilities Total population 4,726.6 268.3 4,658.8 254.2 4,595.2 245.1 4,531.1 238.6 4,474.1 227.1 (thousand)* Employed (thousand) 2,973.5 49.4 2,954.3 46.6 3,073.4 49.2 3,068.9 44.2 3,136.3 49.8 Employed as % of the 62.91% 18.41% 63.41% 18.33% 66.88% 20.07% 67.73% 18.52% 70.10% 21.93% total population in the age cohort Unemployed (thousand) 302.5 9.9 245.3 7.0 204.1 4.6 170.8 4.0 140.1 4.0 Labor force (employed 3,276.0 59.3 3,199.6 53.6 3,277.5 53.8 3,239.7 48.2 3,276.4 53.8 plus unemployed; thousand) Labor force participation 69.31% 22.10% 68.68% 21.09% 71.32% 21.95% 71.50% 20.20% 73.23% 23.69% rates Persons not in labor force 30.69% 77.90% 31.32% 78.91% 28.68% 78.01% 28.50% 79.84% 26.77% 76.27% (inactive) rates Employment rate 90.78% 83.30% 92.31% 86.94% 93.77% 91.45% 94.72% 91.70% 95.72% 92.57% Unemployment rate 9.23% 16.69% 7.67% 13.06% 6.23% 8.55% 5.27% 8.30% 4.28% 7.43% Registered unemployed 330,816 16,923 284,706.8 15,760 236,752 13,466 202,994.2 13,627 185,266 11,873 in NEA** Unemployment rates 10.01% 25.49% 8.90% 25.32% 7.22% 21.57% 6.27% 23.53% 5.57% 19.29% based on NEA*** Source: NSO LFS at the project team request and own calculations. *Total means all population in the respective age group. **National Employment Agency (NEA) data. ***Calculated as a ratio between registered unemployed in NEA to the labor force calculated as the number of employed from LFS plus unemployed from NEA. 123 In the case of working age adults with disabilities, who have acquired disability as adults,213 there is no empirical research to investigate why most of them leave employment; anecdotal evidence cited by disability advocates and media suggests that many face barriers such as lack of rehabilitation, workplace accommodation, skills training, flexible work environment, etc. According to NEA data, in 2019, 40.0 percent of registered unemployed persons with disabilities were without qualification and 30.0 percent had only primary education or less than primary education. The situation is similar in the group of inactive working age persons with disabilities. LFS 2019 data show that about 38.0 percent of them had basic or lower education (in 2015, the percentage was 41.0). This statistic corroborates findings from the World Report on Disability that persons with lower education levels tend to experience higher rates of disability.214 Unfortunately no labor market data disaggregation between working age persons with disabilities since childhood and working age adults who have acquired disability as adults is available. Where does Bulgaria stand relative to other EU countries? This question is quite difficult to answer in any comprehensive manner. Internationally comparable data on labor market participation of persons with disabilities are not easy to find and when available they are often outdated. Frequently, data are not directly comparable because definitions of labor market indicators differ from standard ILO definitions. Moreover, in some countries, working age persons with disabilities receiving a disability pension are not allowed to work, which makes comparisons across countries even more complicated. Having these caveats in mind, we present some relatively comparable data. As a reminder, in Bulgaria, in 2019, the LFS estimated unemployment rate of persons with disabilities was 7.3 percent. Similarly calculated unemployment rates in Lithuania and Latvia in 2018 were 21.9 and 22.4 percent respectively. In Germany215, in 2018, based on the Micro Census data, the labor force participation rate of persons with disabilities aged 20-64 was estimated at 30.0 percent, employment rate at 55.0 percent and unemployment rate at 11.2 percent. In 2016, the unemployment rate of persons with disabilities was estimated at 10.1 percent, in Belgium at 12.0 percent and in the Czech Republic at 16.4 percent. 6.2. Regulatory framework for labor market policies for persons with disabilities Key legislation pertaining to labor market inclusion of persons with disabilities are the Labor Code, the Law on Civil Servants, the Employment Promotion Act, the Persons with Disabilities Act and their bylaws. Other important pieces of legislation include the Law on Personal Income Tax, the Law on Corporate Income Taxation, and the Law on Local Taxes and Fees. Active labor market programs (ALMPs) and labor mediation services provided by National Employment Agency and its labor offices play partially a role of vocational rehabilitation services in Bulgaria, especially those that include training, vocational orientation, and psychological support. Vocational rehabilitation apart from active labor market programs was recently introduced by two new laws - the 2019 Persons with Disabilities Act (PDA) and the 2020 Social Services Act (SSA). The PDA216 defines occupational and vocational rehabilitations for persons with disabilities, while the SSA introduces support for acquiring labor skills as one of the main types of social services.217 These 213 National Strategy for persons with disabilities in Bulgaria 2021-2030, http://www.strategy.bg/PublicConsultations/View.aspx?lang=bg-BG&Id=5514 214 World Health Organization and World Bank. 2011. World Report on Disability. Geneva and Washington, D.C. 215 Press release #N 026 from 26 May 2020 (www.destatis.de), 216 More details are provided later in this chapter. 217 Social Services Act, Article 15, item 6. https://www.google.bg/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwinifPVj5TvAhUWPuwKHb 2VChcQFjABegQIAhAD&url=https%3A%2F%2Fwww.mlsp.government.bg%2Fuploads%2F35%2Fsv%2Fzakon- za-socialnite-uslugi-21072020.rtf&usg=AOvVaw14Jm5qqE5Acmvtg8V93SHr 124 provisions are yet to be implemented. Moreover, currently the only service provider is NEA and its labor offices. Thus, main labor market services for persons with disabilities are Active Labor Market Programs defined in the Employment Promotion Act (EPA) and the annual National Action Plan for Employment (NAPE). In addition, there are employment programs for persons with disabilities implemented by the Agency for Persons with Disabilities. There are also projects under the Operational Program Human Resources Development (OP HRD) financed under the European funds and the national budget and implemented either by NEA or the Ministry of Labor and Social Policy as the managing authority of the OP HRD. Below we briefly describe main laws regulating labor market inclusion of persons with disabilities in Bulgaria (see also Chapter 2 of this Report and Annex 2 to this Chapter). Labor Code (LC)218 regulates labor relations between the employee and the employer. Chapter 15, Section III regulates special protection of persons with reduced work capacity due to general illness or occupational disease/work injury, the grounds for job reassignment and the forms and manner of its implementation. The provisions are set within the framework of clear and unequivocal prohibition of direct or indirect discrimination in exercising labor rights and obligations, including based on the presence of mental, sensory, intellectual, or physical disabilities. Article 315219 obliges an employer with more than 50 employees to determine annually jobs suitable for reassignment220 of persons with reduced work capacity ranging from 4 to 10 percent of the total number of employees depending on the industry. Their exact number is determined by an Ordinance of the Ministry of Health and Ministry of Labor and Social Policy.221 The practice shows that employers reserve job positions for reassignment, but they often do not fill them. Moreover, they are not obliged to announce these jobs through the NEA Labor Offices, making this obligation more of an intent rather than an effective policy measure. The Code also obliges employers with more than 300 employees to open specialized work units as state or municipal enterprises for persons with reduced work capacity.222 There is little evidence that this law requirement is being implemented on a larger scale. For instance, in December 2020, only 5 specialized municipal enterprises existed.223 The Labor Code provides special protection for persons with reduced work capacity: • An employee who, due to illness or occupational injury, is unable to perform her/his job, but can perform other suitable work or the same job under adjusted conditions, with the same employer and without risk to his/her health should be transferred to another job or her/his work conditions should be accommodated, as advised by the health authorities. • Reassigned employees are prohibited from working night shifts and overtime, except with their personal consent and, if this does not adversely affect their health, according to the conclusion of the health authorities. 218 The Labor Code, https://www.noi.bg/images/bg/legislation/Codes/KT.pdf 219 Article 315, paragraph 1, Labor Code. Ibid. 220 According to Article 314, reassignment is when an employer moves an employee with reduced work capacity to another job or to the same job with adapted work conditions upon recommendation from MAC or TMEC/NMEC. Ibid. 221 “Ordinance for determining workplaces suitable for job reassignment of persons with reduced work capacity”. https://www.ctc-bg.com/wordpress/wp- content/uploads/2019/01/NAREDBA_RD071_ot_2022012_g_za_opredelqne_na_rabotnite_mesta_podhodqsi _za_trudoustroqvane_na_lica_s_n.pdf 222 Article 316. Ibid. 223 These enterprises are in the following cities/towns: Sofia, Etropole, Samokov, Pirdop and Stara Zagora. 125 • Employees with reduced work capacity of 50 percent and above are entitled to a basic paid annual leave of not less than 26 working days, which is 6 days more than the basic paid annual leave of 20 working days for employees among general population. It is prohibited to dismiss employees suffering from certain diseases and those who were reassigned because of their reduced work capacity, as specified in an ordinance of the Minister of Health. 224 Permission for dismissal on certain grounds can happen only after obtaining an opinion of relevant TMEC. While this legal provision is designed to guarantee the right to work of persons with disabilities, often it turns to be a barrier to employment; employers refrain from keeping/hiring persons with disabilities since it is difficult to terminate their contract later. Civil Servant Act (CSA):225 The Act, which was adopted in 2008226 introduced a mandatory requirement for reserveing a certain number of positions in the state administration for persons with permanent disabilities: 2 percent of the total number of positions in administration employing more than 50 people and 1 position in administration employing 26 to 50 people. The positions are filled on a competetvie basis from the pool of persons with permanent disabilities. Corporate Income Taxation Act227 stipulates that the corporate tax228 is 100 percent allocated to specialized enterprises or cooperatives of persons with disabilities within the meaning of the PDA. Eligible entities should be members of the national representative organizations for persons with disabilities, and at least 20 percent their staff are people with poor eyesight, or at least 30 percent are people with poor hearing, or at least 50 percent are people suffering from other impairments.229 The exemption is allowed when the exempted tax is spent only on integration of persons with disabilities or on maintaining and creating new jobs for people with reduced work capacity. Employment Promotion Act (EPA):230 This act regulates promotion and retention of employment, vocational guidance and adult education, labor market intermediation and supported employment.231 EPA describes labor market interventions to stimulate demand, employment, and retention of persons with disabilities. It refers to a person with permanent disability as a person with a permanent disability acquired due to an anatomical, physiological, or psychological disability; the person remains with permanently reduced capacity to perform activities in a manner and to the extent possible for a healthy person, and for which the TMEC has established a degree of reduced work capacity of 50 percent and above. EPA describes a range of ALMPs for persons with disabilities. They are implemented on annual basis through the NАPЕ, the main financing instrument for funding ALMPs.232 Persons with Disabilities Act (PDA),233 regulates employment of persons with disabilities as their basic right, along with health care, education, housing, accessible environment in urban areas and public 224 Article 333, paragraph. 1, item 2 and item 3 and paragraph 2, Labor Code https://www.noi.bg/images/bg/legislation/Codes/KT.pdf 225 Civil Servant Act - https://www.nssi.bg/images/bg/legislation/laws/ZDSl.pdf 226 Article 9a. Ibid. 227 The Corporate Income Taxation Act. https://nra.bg/en/page?id=522 228 Article 178. Ibid. 229 If the share of persons with disabilities is lower than required, the corporate tax is exempted proportionally. 230 The Employment Promotion Act. https://www.az.government.bg/web/files/PageFile/74/16816/zakon-za- nasyrchavane-na-zaetostta.pdf 231 Supported employment was added in 2016. According to the Supplementary Provisions, Item 45, Employment Promotion Act, “Supported employment is the provision of assistance to unemployed persons with permanent disabilities and to other disadvantaged groups in the labor market, according to their specific needs, for work in non-subsidized jobs.” 232 Main programs and measures under EPA are presented later in this chapter. 233 The Persons with Disabilities Act. https://ahu.mlsp.government.bg/portal/document/76193 126 buildings, transport, culture, sports, personal life, public and political life, justice, and others. It stipulates that person with disabilities have the right to rehabilitation, which is complex and can be occupational, vocational, medical, social, and psychological. • Occupational rehabilitation promotes the right to employment for persons with disabilities through occupational therapy; social inclusion through work; providing guidance services for employment, training, and an appropriate form of employment in specialized, sheltered or regular work environment; and adapting work environment to provide employment for persons with disabilities. • Vocational rehabilitation enables persons with disabilities to overcome barriers to access and return to work in a particular profession. Vocational rehabilitation aims to develop work knowledge and skills of persons with disabilities, supports preparation for work and provides employment appropriate to their health condition, education, and qualifications. It includes: an assessment of professional suitability of persons with disabilities, vocational consultations based on it; professional training; providing support and employment assistance services; providing appropriate support for overcoming the barriers of the functional limitations for practicing the acquired profession, adapting workplace, and working conditions according to the needs of the person with disabilities and others. MLSP and NEA implement employment policy for persons with permanent disabilities. Together with other stakeholders they develop and propose for financing and implementation programs and measures to promote employment and provide equal opportunities through socio-economic integration of persons with permanent disabilities (EPA).234 Employment of persons with disabilities takes place in regular, specialized, and sheltered work environment. To support employment of persons with permanent disabilities in a regular work environment, employers should employ workers with permanent disabilities under a quota system as follows:235 (i) employers with 50 to 99 employees - one person with permanent disabilities; (ii) employers with 100 and more employees - two percent of their average staff number. An employer is obliged to adapt the workplace to the needs of the person with disability when hiring him/her, if necessary, depending on the type and degree of disability. The Agency for Persons with Disabilities may finance an employer under the National Employment Program for Persons with Disabilities for:236 providing access to, adaptation and equipment to adapt the workplace, qualification and re- qualification, respectively training for professional and on-the-job development and other activities. In addition, PDA regulates other forms of financial support for employment of persons with disabilities which is operationalized in annual programs implemented by APD (see below). 6.3. Active Labor Market Programs for Persons with Disabilities Below, we describe ALMPs that (also) play a role of vocational and occupational rehabilitation. Both were introduced by PDA; but they are yet to be operationalized and implemented (for more details on programs, see Annex 1 to this Chapter). In Bulgaria, as noted, NEA is responsible for implementation of the state policy on employment promotion.237 It delivers services such as labor mediation, subsidized and temporary employment, training, professional and job guidance, motivation, psychological support, etc. This is a standard 234 Article 36, paragraph 1. Ibid. 235 Article 38. Ibid. 236 Article 44. Ibid. 237 MLSP, Employment Agency. https://www.az.government.bg/en/ 127 menu of labor market interventions and all who need them can access them, including persons with disabilities, provided that they register as unemployed with NEA. In addition to a standard menu of services, NEA also implements measures specifically designed for persons with permanent disabilities: (i) Specialized measures to encourage employers to employ persons with reduced work capacity and specific job requirements: • Subsidizing employers (for 18 months) for each created job that employs unemployed young people with permanent disabilities up to 29 years of age or military persons with disabilities, as well as young people from social care institutions.238 • Labor mediators measure. Labor mediators239may apply to receive funds for supported employment240 for each unemployed person with permanent disabilities or other disadvantaged groups on the labor market, directed by Labor Offices, who has been employed in a non-subsidized job for at least 12 months.241 • Subsidy to employer. For each job created for an unemployed person with permanent disabilities, referred by the Labor Office, the employer shall be provided with subsidy of up to 75 percent for 3 to 12 months.242 • Subsidizing employment of the unemployed with permanent disabilities, including military persons with disabilities, directed by the units of the NEA for full-time or part-time employment period, not exceeding 12 months.243 The subsidy lasts six months and the employer should keep the employee for another 6 months. The monthly wage is 256 euro (500 BGN) for people with up to secondary education, and 281 euro (550 BGN) for those with tertiary education.244 (ii) Programs to support inclusion of persons with permanent disabilities in employment programs: • The National Program for Employment and Training of Persons with Permanent Disabilities245 implemented by NEA is a fully subsidized program for unemployed persons with permanent disabilities, who are hired for 24 months. Priority is given to persons with 71 percent and over of reduced work capacity; military persons with disabilities; and persons with sensory and mental disabilities. Priority for participation in the program is given to those employers who have concluded a contract to finance activities for adaptation and/ or equipment at workplaces for persons with permanent disabilities and are providing access to workplace, qualification and re-qualification courses, training for professional development and other activities under the above-mentioned National Employment Program for Persons with Disabilities.246 • Two additional programs with disability components, implemented by NEA and financed through the Operational Program “Human Resources Development” (OP HRD) with the European Social Fund support are: “Training and employment for youth”247 (age 15-29) with 238 Article 36, paragraph 2, EPA. https://www.az.government.bg/web/files/PageFile/74/13555/zakon-za- nasyrchavane-na-zaetostta.docx 239 Registered under EPA, Article 27, paragraph 2, item 2. Ibid. 240 Article 30a, paragraph 1, item 23. Ibid. 241 Article 43a. Ibid. 242 Article 51, paragraph 2. Ibid. 243 Article 52, paragraph 1. Ibid. 244 https://www.az.government.bg/pages/merki-po-znz-naemane-na-bezrabotni-lica-s-traini-uvrejdania/ 245 https://www.az.government.bg/pages/nacionalna-programa-zohtu/ 246 Article 44, paragraph 1. PDA. https://ahu.mlsp.government.bg/portal/page/3 247 https://www.az.government.bg/pages/procedura-obucheniya-i-zaetost-za-mladite-hora/ 128 budget of 59.3 million euro and “Training and employment”248 (for age 30+) with budget of 102.8 million euro. Both projects are planned to be implemented in the period 2015-2023. With the average amount of approximately 25 million euro per year these two projects complement and expand ALMPs financed through NAPE. Both projects have special second components which target directly inactive and unemployed persons with disabilities. Priority is given to those who have disability degree of over 75 percent. These two programs allow for higher subsidies based on monthly insurance income compared to NAPE’s close-to-minimum- wage remunerations. They also add coaching to the traditional training and subsidized employment. Finally, they provide a 5–6-year access continuity due to the longer period of implementation (2015-2023). ALMP statistics and funding As pointed out, ALMPs, including for persons with disabilities, are mostly implemented by NEA and they are financed mainly through NAPE (the state budget) and OP HRD (co-financed by the European Social Fund and the national budget). Whereas NAPE is an annual financing instrument, the OP HRD depends on the program cycle of the European Structural Funds. The annual state budget for all ALMPs of 35.8 - 37.3 million euro249 has remained almost unchanged since 2009. As noted above, it is supplemented significantly through OP HRD. Programs and measures to create jobs for persons with disabilities Table 6.2: Number of employed persons with disabilities in main ALMPs under NAPE 2015 2016 2017 2018 2019 Total programs and measures for employment and training 2,609 2,296 3,202 2,979 2,332 under NAPE National Program for Employment and Training of People with 2,295 2,007 2,606 2,367 1,819 disabilities (NPETPWD) Share of the main program (NPETPWD) to all NAPE support 88% 87% 81% 79% 78% Measures for employment and training under EPA financed by 302 285 596 612 513 NAPE* Source: National Employment Agency and own calculations. * Measures under Employment promotion Act (EPA) Article 36, paragraph 2, Article 43 (a), Article 51, paragraph 1 and 2. Data presented in Table 6.2 (and Figure 6.1) show that the numbers of employed persons with disabilities under ALMPs do not follow any specific trend. They go up and down: between 2,296 in 2016 and 3,202 in 2017. Contributing factors to this situation might include the unchanged NAPE budget, a gradual increase in the minimum wage250 which is an important benchmark for individual monthly subsidies, as well as decreasing numbers of registered unemployed persons with disabilities (Table 6.1). On the other hand, in 2018-2019 period, when OP HRD programs targeted at persons with disabilities started being implemented, they contributed to additional employment of 4,495 and 5,568 persons with disabilities in 2018 and 2019 respectively. This suggest that OP HRD programs may be crowding out NEA programs to a certain extent. Moreover, given that wages under OP HRD are higher, they may also signal higher than estimated reservation wage among persons with disabilities. 248 https://www.az.government.bg/pages/procedura-obucheniya-i-zaetost/ 249 70-73 million BGN. 250 184 euro (360 BGN) in 2015 and 286 euro (560 BGN) in 2019 (http://trudipravo.bg/znanie-za-vas/83- usefullinfo/infsp/1050-minimalna-rabotna-zaplata-za-stranata-za-perioda-2000-2019-godina) 129 The main program for persons with disabilities, the National Program for Employment and Training of Persons with Disabilities provide between 79 and 88 percent of NAPE employment for persons with disabilities. Figure 6.1: Number of persons with disabilities emp loyed in ALMPs implemented by NEA 6,000 5,568 5,000 4,495 Number of People with 4,000 Disabilities participated in 3,202 subsidised employment funded 2,979 by NAPE 3,000 2,609 2,296 2,332 2,000 Number of People with disabilities employed in ALMP 1,000 financed only by OP HRD 0 2015 2016 2017 2018 2019 Source: National Employment Agency data Four specialized active labor market measures related to subsidized employment (specified in EPA251), and several other measures targeting disadvantage groups, including persons with disabilities, create around 300-600 jobs or 12-21.0 percent of the total number. In addition, 50-100 new jobs have been created each year through programs financed by APD. In all, one can conclude that despite significant resources, the impact of ALMPs specifically targeted at creating jobs for persons with disabilities has been very small. The number of employed persons with disabilities under some measures can be counted on fingers, raising questions about the supply of potential candidates and the ALMPs’ cost-efficiency. Moreover, many of the measures are similar and mostly provide subsidies for jobs. The subsidy is time bound in expectation that a person would remain on the job. The share of training expenditure in the overall budget of NEA for persons with disabilities is around 0.3% in 2018-2019. The number of persons with disabilities in training varies between 100 for the period 2015-2017 to 180-400 in 2018-2019 when OP HRD financing of ALMPs was introduced. The numbers of beneficiaries and spending are negligible. Other ALMP interventions As noted, to use services provided by NEA, a person looking for a job, including persons with disabilities, must register as an unemployed person, signaling that he/she is looking for a job. In 2019, 11,487 persons with disabilities were registered as unemployed with NEA. All of them had a personal development plan prepared by NEA and most were provided some type of mediation services (Table 6.3). The number of persons with disabilities placed in the jobs in the primary labor market has ranged between 6.7 and 7.2 thousand annually in the observed period. The introduction of quotas in 2019 did not fulfill expectations (see Box 1 on the employment quotas for persons with disabilities). The 251 EPA Measures under Article 36, paragraph 2, Article 43 (a), Article 51, paragraph 1 and 2. Ibid. 130 reasons include: many employers declared under their quota persons with disabilities who had already been employed by them; some employers have complained that the supply of skills they are looking for is limited (which is a situation that allows them to be released from the quota obligation;252 some employers chose to pay fine (30% of the minimum wage for every unfilled position);253 and some employers declared work conditions not suitable for persons with disabilities.254 According to the General Labor Inspectorate Annual Report in 2019,255 from August to December 2019, 8,129 persons with disabilities were reported by 1,811 employers as employed under the quota obligations; 53 employers declared unsuitable working conditions, 234 employers preferred to pay compensations which affected 2,158 work places for persons with disabilities. However, there is no data on how many persons with disabilities had already been employed with the employers who reported them as employed under the quota system. Table 6.3: Labor market mediation services for persons with disabilities 2015 2016 2017 2018 2019 Number of people with disabilities provided with 16,840 14,127 12,878 14,460 11,487 mediation services by NEA Number of people with disabilities with personal 16,840 14,127 12,878 14,460 11,487 development plans by NEA Number of people with disabilities who started 7,540 9,510 9,028 13,093 13,954 work with the help of NEA mediation services Number of people with disabilities started work 3,606 6,775 7,365 7,023 7,215 on primary LM Share of people with disabilities who started work on primary LM out of those who started work 48% 71% 82% 54% 52% with the help of NEA Number of people with disabilities being trained 126 102 89 95 98 with the help of NEA Source: National Employment Agency (NEA) and own calculations 252 Article 38, paragraph 3, item. 2, PDA, https://ahu.mlsp.government.bg/portal/page/3 253 Article 38, paragraph 6. Ibid. 254 Article 38, para 3, item 1. Ibid. 255 https://www.gli.government.bg/sites/default/files/upload/archive/docs/2020- 08/Godisen_doklad_2019.pdf 131 Box 1: Employment quotas for persons with disabilities At its simplest, quota legislation requires private and/or public sector employers, who employ a certain minimum number of workers, to ensure that a given proportion of employees consists of persons with disabilities. The quota system was introduced for the first time after the WWI (at about 1920) in Germany, Austria, France, Poland, and Italy to help employ disabled war veterans. The 2019 International Labor Organization (ILO) review of the quota schemes for employment of persons with disabilities shows that 103 countries had some form of quotas. 256 The Review (Volume 1) found that:257 • 33 of 103 countries (32.0 percent) have quotas backed by levies or fines; 64 (62.0 percent) have binding quotas (though it is unclear from the available information whether or how these are enforced); and 6 (6.0 percent) have quotas introduced by government decisions or decrees, rather than laws, so may not be binding. • The quota schemes vary considerably in terms of employers covered and the level of the quota obligation. They also vary in terms of who stands to benefit from the quota provisions. Enforcement methods differ too, as do the measures in place to compensate employers who fulfill the quota obligations and sanction those who do not comply. • Out of 100 countries for which information was available, in 70, the quota schemes applied to employers in both the public and private sectors; in 24 countries to public sector employers only; and in 6 to private sector employers only. In 53 countries the quota applied to employers above a certain size of workforce, with the smallest employers exempt. In 5 countries, the quota applied to all employers. • The lowest threshold was generally 20 employees, with employers with a workforce greater than this subjected to the quota obligation. A few schemes set the threshold lower than this, while in some cases the threshold was far higher – 100 employees in several cases, and 1000 in one case. In some cases, certain sectors and types of jobs are exempt from the quota obligation. • There is considerable variation between countries in the level of obligation posed, with the specified quota rates ranging between 1 and 10 per cent. One in five of the schemes set the quota requirements at between 1 and 2 percent; just under two thirds (62.0 percent) set the obligation at between 2 and 5 percent; 8.0 required employers to fulfill a quota of between 6 and 7 percent. • In order to benefit from the quota provisions, people with disabilities are generally required to register as disabled or be certified as having a disability following an assessment. Interestingly, while 103 countries have some type of quota requirements, as the ILO Review found, information on how effective they are in increasing employment of persons with disabilities is sparse. Sporadic evidence from many countries suggests that employers are not keen on quotas and often choose to pay fines rather than to employ persons with disabilities. In many cases, the firms retain workers who have become disabled and count them towards the quota. Some firms hire persons with disabilities “notionally”, they receive the wage but have no obligation to turn to work, which defies the purpose of the quotas. One of the rare examples of empirical analysis of the quota system performance was done for Spain. 258 A statistical analysis of data for 4,000 firms found that the impact of the quota system was low. 256 ILO. 2019. Promoting Employment Opportunities for People with Disabilities Quota Schemes. Volumes 1 and 2. Geneva. https://www.ilo.org/global/topics/disability-and-work/WCMS_735531/lang--en/index.htm, and https://www.ilo.org/wcmsp5/groups/public/---ed_emp/-ifp_skills/documents/publication/wcms_735532.pdf 257 Ibid. Volume 1. pp. 1-4. 258 Malo, M. and Pagan, R. 2014. “Hiring workers with disabilities when a quota requirement exists: The relevance of firm’s size”. https://www.researchgate.net/publication/257021597 132 Between 2015–2017, targeted funds for persons with disabilities were 3.58-6.144 million euro funded through NAPE (Figure 6.2); between 10-16% of the total NAPE budget, covering around one third of the registered unemployed persons with disabilities (16,923 and 13,466 persons, respectively). In 2018 and 2019, when OP HRD funds had become available, almost all registered unemployed persons with disabilities were covered by active labor market programs and mediation services. In 2019, out of 11,873 registered unemployed almost 7,998 participated in ALMPs and 7,215 persons with disabilities were placed on the primary labor market. Table 6.4: Costs of measures for persons with disabilities implemented by NEA (in Euro) 100% 5,498,372 90% Costs of subsidised employment for 80% 6,048,938 People with disabilities in NAPE 70% 3,582,739 60% 50% 6,144,031 27,938,390 Costs for participating People with 40% 4,712,558 30% disabilities in ALMP interventions 6,895,269 implemented by NEA and financed by OP 20% HRD 10% 0% 2015 2016 2017 2018 2019 Impact assessment of ALMPs Below (Table 6.4) we presented some results from two impact evaluation reports, initiated by NEA and conducted by an external contractor. The evaluation covered ALMPs implemented by NEA in 2015259 and 2017.260 The main indicators used by the authors are a gross and a net effect of the evaluated programs and measures. The gross effect is the relative share of persons who have had subsequent employment, i.e., have had a long-term stay in the labor market after the programs completion. The analysis is focused on persons who participated in ALMPs and on the control group. The net effect is calculated from the gross effect for those who participated in the programs minus the so called "deadweight" effect,261 the substitution effect,262 and the displacement effect.263 In 2015, the major program for persons with disabilities (the National Program for Training and Employment of Persons with Disabilities) is among those with the lowest gross impact - 27.6 percent. 259 “E – Research” Consortium, “Elaboration of a Subsequent Assessment of the Effect of the Active Labor Market Policy, Financed by State Budget Resources at Individual Level (Net Effect) for 2015”, Sofia, 2017, https://www.mlsp.government.bg/uploads/26/zaetost/final-report-print-en.pdf 260 “E – Research” Consortium, “Elaboration of a Subsequent Assessment of the Effect of the Active Labor Market Policy Financed by State Budget Resources at Individual Level (Net Effect) of the Programs and Measures, Included in the National Employment Action Plan for 2017”, Sofia, 2019, https://www.mlsp.government.bg/uploads/1/net-effect-final-report-en1.pdf 261 The “deadweight” is measured by the number of unemployed perso ns (or their relative share) from the control group who have not been included in the specific program/measure, but nonetheless they found a job. 262 The “substitution” effects happens when an employer employs a subsidized worker in place of a regular worker who has been dismissed or has never been employed. 263 The “displacement” effect is observed when the actions of an employer participating in a given program or measure have a negative effect on the actions of another employer who does not directly participate in the program/measure and, thus, the latter is forced to reduce its personnel. 133 Only two programs – one targeting long-term unemployed and the other about assistants for person with disabilities performed worse. The average gross rate of all programs and measures in the same year was 59.3 percent. However, the National Program recorded significant increase in 2017, reporting a 65.4 percent gross effect, at 62.3 percent average for all programs and measures. The impact evaluation reports showed that the effect of the programs depends on disability level. The higher the percentage of disability is, the more difficult it is to enter the labor market. Data from the impact evaluations show that persons certified as having a degree of disability higher than 50 percent have an overall effect of 5.6 percentage points lower than those who have less than 50 percent disability (in Bulgaria, disability of less than 50 percent denotes mild/no disability and gives no access to any programs specifically targeted to persons with disabilities). Likewise, persons with more than 70 percent of disability have lower effect by 5.7 percentage points compared to those with less than 70 percent disability. These results suggest the need for differentiated interventions. 134 Table 6.4: Gross and net effects of programs and measures for persons with disabilities implemented by NEA and included in NAPE in 2015 and 2017 2015 2017 Gross Gross Gross Gross PROGRAMMES AND MEASURES effect of Net effect of Number of effect of Number of effect of Net effect the effect the participants the Test participants the Test (p.p.) Control (p.p.) Control group (%) group (%) group (%) group (%) Average all programs 59.3 62.3 National program for disabled people’s training and 1,130 27.6 18.0 5.5 756 65.4 34.2 22.9 employment Encouraging employers to hire unemployed people aged under 29 with permanent disabilities, including disabled soldiers, as well as young people from social institutions who 18 58.6 34.0 21.7 5 completed their education (article 36, paragraph 2 of the EPA) Encouraging employers to create jobs for unemployed people with permanently reduced capacity to work (article 57 50.5 39.0 6.6 Х 52, paragraph 1 of the EPA) Encouraging employers to hire unemployed people with permanently reduced capacity to work on a temporary, 66 49.6 24.0 21.7 Х seasonal or part-time job (article 52, paragraph 2 of the EPA) Encouraging employers to hire full- or part-time unemployed persons with permanent disabilities, incl. military invalids Х 110 59.0 44.0 11.8 (Article 52 of the EPA) Encouraging employers to hire unemployed persons with Х 303 51.5 27.5 20.9 permanent disabilities (Article 51, paragraph 2 of the EPA) Source: “E – Research” Consortium, “Elaboration of a Subsequent Assessment of the Effect of the Active Labor Market Policy, Financed by St ate Budget Resources at Individual Level (Net Effect) for 2015”, Sofia, 2017, https://www.mlsp.government.bg/uploads/26/zaetost/final-report-print-en.pdf and “E–Research” Consortium, Elaboration of a Subsequent Assessment of the Effect of the Active Labor Market Policy Financed by State Budget Resources at Individual Level (Net Effect) of the Programs and Measures, Included in the National Employment Action Plan for 2017, Sofia, 2019, https://www.mlsp.government.bg/uploads/1/net-effect-final-report-en1.pdf 135 Other programs for persons with disabilities In addition to labor market inclusion programs implemented by NEA, the Agency for Persons with Disabilities implements several labor market inclusion programs (Table 6.5) stipulated by PDA. The programs are comparatively small in terms of employment creation and impact on the workplace adaptation. All programs listed in Table 6.5, except from the National program for employment of persons with disabilities, have limited budgets (they target around 221 specialized enterprises and cooperatives and small group of entrepreneurs). The National program for employment of persons with disabilities, implemented by APD, has a budget of approximately 2 million euro per year. However, this budget had stayed underspent (prior to 2019, this program had a budget of 100-150 thousand euro per year; then in 2019 the program was restructured into a much bigger one with significant increase in its budget – partially due to the introduction of the employment quotas to provide additional financial incentives to the employers). The actual implementation of the program had stayed at the levels prior to its national upgrade, which brings back the question on the actual (and realistically assessed potential) supply of labor by persons with disabilities in the labor market. A different question is whether APD should be implementing programs related to labor market inclusion, when there is already NEA. NEA is a national agency whose task is to facilitate labor market inclusion of all persons seeking job. As experience shows, integrated programs, including workplace adaptation, flexible work arrangement, vocational and occupational rehabilitation, etc. are more likely to succeed and produce lasting results. Besides, NEA has offices across the country and is much better placed to work with clients on the ground. Table 6.5: Investment support programs for labor market inclusion of persons with disabilities based on PDA and implemented by the Agency for Persons with Disabilities 264 Name / PDA Activities Target groups Budget in euro Indicators reference Article 50: Specialized enterprises and cooperatives of persons with disabilities and labor-medical Specialized entities are enterprises and reimbursed 50 per 50% refund of paid cooperatives of cent of the due social security persons with social insurance contributions to disabilities and Plan: 357,904 102 organizations contributions for employers of labor-medical Report: 659,579 supported the state social persons with entities insurance, disabilities Employees with compulsory health disabilities over insurance and 50% additional compulsory pension insurance of the persons employed. The reimbursed funds should be 264 APD Annual Report of APD 2019, https://ahu.mlsp.government.bg/portal/document/73334/ 136 Name / PDA Activities Target groups Budget in euro Indicators reference used for investments, rehabilitation and social integration of persons with permanent disabilities and their supporting staff. Specialized enterprises and Investment in cooperatives of the equipment, persons with Article 49: machinery and disabilities and Investment intangible assets labor-medical projects supporting leading to better entities 13 supported business economic results Plan: 766,938265 enterprises development of and related to the Unemployed (both Report: 443,791 25 new jobs specialized creation and/or registered and not enterprises and maintenance of registered with cooperatives. workplaces for NEA) and/or persons with employed persons disabilities with disabilities over 50% Improvement of Specialized working enterprises and conditions, cooperatives of Article 49: occupational safety persons with Investment project and health. disabilities and 11 supported supporting social Training for labor-medical enterprises development of Plan: 766,938 employed. entities 350 workplaces specialized Report: 174,193 Introduction of impacted enterprises and different types of Employed persons cooperatives. quality with disabilities management over 50% systems. Support for establishing new Article 46 businesses Persons with Entrepreneurship 16 new companies Investments in permanent Plan: 306,775 support for and respectively 16 equipment, disabilities over Report: 155,765 persons with new jobs machinery and 50% disabilities. intangible assets for new business. Article 44: - Providing access Employers 22 employers National program to existing or supported Plan: 2,137,200 for employment of newly created jobs Persons with Report: 115,631 persons with for persons with disabilities over 56 workplaces disabilities permanent 50% impacted 265 The planned budget is for the entire Article 49 including two types of projects directed to (i) business development and (ii) social development of specialized enterprises and cooperatives. 137 Name / PDA Activities Target groups Budget in euro Indicators reference disabilities. Employment period is minimum 36 months. - Adaptation of existing jobs for persons with permanent disabilities, - Equipping new workplaces for persons with permanent disabilities, corresponding to the nature of their disability. - Qualification and re-qualification, respectively training for professional development. 1. Work capacity assessment, 2. Coaching, 3. Psychological support, 4. Medical services, 5. Material and technical equipment, corresponding to the field of Employers economic activity Article 51: People with of the center for Creation of Centers multiple sheltered for sheltered permanent 1 newly created employment and employment for disabilities with Plan: 306,775 Center ensuring the people with focus on people Report: 134,473 acquisition of multiple with intellectual 15 new jobs professional skills, permanent disabilities and 6. Services for disabilities mental health acquisition of disorders professional skills in the respective field of economic activity of the center for sheltered employment, 7. Staff for the funding various supporting services, 138 Name / PDA Activities Target groups Budget in euro Indicators reference 8. Financial incentives for employees with multiple permanent disabilities. The funds for financial incentives may not exceed 50% of the minimum wage for each of them. 9. Providing employment mediation and helping people with multiple permanent disabilities to find and start work in a specialized or regular work environment. Inter-institutional cooperation in the field of labor integration of persons with disabilities Labor inclusion of persons with disabilities is a complex issue that requires intense and effective cooperation of many stakeholders, including employers and persons with disabilities themselves. However, the practice shows that inter-institutional cooperation between main actors such as NEA, APD, TMEC/NMEC, as well as institutions such as Agency for Social Assistance, General Labor Inspectorate, Ministry of Education, and Ministry of Health is not as strong as needed for joint labor inclusion efforts. The integrated support is still to be implemented in practice, no multidisciplinary teams exist, no joint interventions are being implemented, no unified electronic information system is in operation that is accessible for different service and support providers, etc. On the other hand, there are some good examples of inter-institutional cooperation that should be further developed. For example, the National Strategy for Persons with Disabilities and its biennial action plans are products of inter-institutional cooperation at the strategic planning level.266 NEA and SAA have 76 joint one-stops-shop offices267 providing assistance and services to some of the most disadvantaged groups in Bulgaria.268 APD maintains a national data base on persons with disabilities. This data base collates data from SAA, NMEC, National Social Security Institute (NSSI), National Revenue Agency and others. In principle, it should also contain updated information on all persons with disability in Bulgaria, including on benefits they receive. This data base is an incredible source of information not only for evidence-based policies, but also to inform and monitor their implementation. However, APD does not publish any data on its website and the data base (in an 266 National Strategy for persons with disabilities in Bulgaria 2021-2030. http://www.strategy.bg/PublicConsultations/View.aspx?lang=bg-BG&Id=5514 267 Centers for employment and social assistance. https://www.az.government.bg/pages/lice-v-lice/ 268 Annual report on the NEA Annual Action Plan 2017 (pp. 38). https://www.az.government.bg/web/files/PageFile/123/16203/otchet-na-plana-za-dejstvie-2017-g.rar 139 anonymized format) is not accessible and used for the purposes of policymaking, programs’ development and implementation and monitoring (see also Chapter 7). Generally inter-institutional cooperation could be further developed especially in terms of providing integrated/coordinated multisectoral support to persons with disabilities as well as in terms of data exchange. For that, however, a stronger focus on mainstreaming of disability policy is needed. Key messages Low level of labor market participation (i.e.) very high level of labor market inactivity is one of the key features of labor market participation of working age persons with disabilities in Bulgaria . According to the Bulgaria Labor Force Survey 2019, of all estimated working age persons with disabilities, 24.0 were active (i.e., participated in the labor market (either as employed or unemployed) and 76.0 percent were inactive. Of those active, 92.6 percent were employed and 7.4 percent unemployed. Of all working age persons with disabilities, 22.0 percent were employed. If one combine data on employment of persons with disabilities from LFS and data on persons with disabilities formally registered as unemployed from NEA, then the labor force participation rate increases to 27.2 percent and the unemployment rate to 19.3 percent. (This is not methodologically entirely correct, but it may suggest higher unemployment rate among persons with disabilities than what the LFS estimates.) Labor market indicators for persons with disabilities are not different from what one observes in other EU countries. Available and relatively comparable data from other EU countries show similar picture of low labor force participation of persons with disabilities. Some, such as Latvia, Lithuania, France, and Germany feature higher unemployment rates of persons with disabilities than Bulgaria. Factors driving low supply of labor among persons with disabilities are not understood well; understanding them would allow for better tailored policies to maximize their labor force participation. There are two sets of key issues here. One pertains to understanding why most of the working age adults certified as having a disability leave employment upon being certified and rarely, if ever, return to the labor market. In Bulgaria, most of working age adults with disabilities are in their mid-fifties or older, with lower education level and are certified as having reduced work capacity of 50 percent of more due to cancer, musculoskeletal or cardiovascular diseases. The second set pertains to working age adults who have been disabled since childhood. While some barriers to employment faced by either group are similar, there are very significant differences too. Adults in the labor market who have been disabled since childhood tend to have low or no education/skills, they often need higher level of support/accommodation, they face strong societal prejudice, etc. Working age adults who have acquired disability during their adulthood have often completed lower secondary education or higher, most have families, and most are in employment at the time of acquiring disability. For this group, the challenge is to ensure their continued employment, should they wish so, as many may find the opportunity cost of continued employment too high relative to their health concerns and changed life priorities. The labor market policies are focused on unemployed persons with disabilities. There are very few efforts to support continuous employment of persons on a long sick leave, or those referred to TMECs/NMEC for disability certification. Occupational and vocational rehabilitation are underdeveloped, and workplace accommodation is rare. Supporting continued employment of persons on extended sick leave/undergoing certification is potentially a game changer in efforts to increase labor force participation of persons with disabilities, because, as evidence shows, once they leave employment due to disability, they rarely, if ever come back to the labor market. 140 The menu of labor market services is limited, focused on subsidies to employers. NEA does not provide or support services such as coaching to employees and employers, specific workability assessment, work processes and working condition assessment and adaptation, case managers and other staff trained and experienced in working specifically with persons with disabilities, etc. The integrated (multidisciplinary) approach to service provision is undeveloped . The PDA calls for the integration of occupational, vocational, medical, social, and psychological rehabilitation, but this is yet to be put into practice. Projects implemented under OP HRD provide good lessons in the provision of multidisciplinary labor market services to persons with disabilities. The services are not sufficiently tailored to different needs of different groups of persons with disabilities. The current ALMPs do not make difference between different types of disability or different cohorts of persons with disabilities. Such specialization and diversification are pursued in many EU countries (Belgium, France, Netherlands, etc.). Interventions’ tailoring is crucial, as encouraging and supporting continued employment needs a different mix of services than support for entering labor market for young people with disabilities or returning to the labor market for those who have been inactive. Private employers are still skeptical about working with inactive persons with disabilities , particularly persons with intellectual disabilities since childhood . The introduction of quotas for persons with disabilities in 2019 did not turn into expected engine for expanding employment among persons with disabilities (the experience has been similar in other countries: see Box 1 above). Many employers met their quotas by reporting their current employees with disabilities; some chose to pay the fine rather than hire an additional employee, or they just did not manage to find suitable candidates as the supply of labor among persons with disabilities is small. Another reason is that employers are worried about the fact that they cannot easily dismiss a person with a disability due to additional legislative protection. Monitoring and evaluation need strengthening. Although NEA conducted an impact evaluation several years ago and APD commissioned a survey on labor market participation of persons with disabilities in 2019 (the data is not publicly available), there is a need to continuously monitor the performance of programs to support labor market inclusion of persons with disabilities. This is needed for policy adjustments and further development. Available statistical information suggests modest impact and high cost of implemented interventions. We thus recommend: Conduct a study on determinants of labor force participation of persons with disabilities, with the following cohorts in focus: first time entrants with disabilities into the labor market (young adults with disabilities), adults with disabilities since childhood and adults with disabilities acquired in adulthood/ reduced work capacity who are employed but may leave the employment due to disability and older adults (past mandatory retirement age) participating in the labor market. Employed, unemployed and inactive in the labor market participants should be included in the study. Disaggregation by age, gender, education, disability level and duration, income, etc. by the cohorts is important too. Develop and deploy labor market policies specifically targeting adults with disabilities at risk of leaving the labor market because of disability. The objective is to encourage/support their continuous employment in the same job with the same employer, different job with the same employer or a new job with a new employer (should they wish to remain employed). Here, a multidisciplinary approach with collaborative effort including a person herself/himself, NEA, health and social services and social assistance authorities at the local level, and employers is needed. 141 Establish in NEA a specialized unit for labor market inclusion of persons with disabilities with case management approach for groups requiring longer term and complex interventions to support their inclusion in the labor market. Consolidate labor market interventions in support of employment of persons with disabilities under NEA. Tailor programs to specific needs of different groups of persons with disabilities and increase the menu of services, including vocational and occupational rehabilitation. Foster multidisciplinary, integrated approach in assessing the needs, developing a plan of support, and implementing it. Systematically monitor and evaluate programs for evidence-based policy development. Plenty of data is already collected in Bulgaria but its potential for statistical analysis is yet to be utilized. The APD’s Register of Persons with Disabilities contains a wealth of data on labor market activities of each person with disabilities. SAA also collects data through the individual needs assessment. These data need to be publicly available for analysis and policy making (in anonymized format). 6.5. Annex 2: Description of active labor market programs for persons with disabilities Active Labor Market Interventions are regulated mainly by the Employment Promotion Act and the Persons with Disabilities Act. Vocational and occupational rehabilitation were introduced by PDA (2019). However, neither explicit financial instruments nor designated entities that would deliver vocational and occupational rehabilitation programs have been determined yet. NEA labor market interventions comprise traditional services such as labor mediation, subsidized and temporary employment, training, professional and job guidance, motivation, psychological support, etc., and persons with disabilities have access to them as everyone else. In addition, there are specific labor market programs for persons with disabilities, regulated by EPA and financed through NAPE: A. Specialized measures, implemented by NEA to encourage employers to employ persons with reduced work capacity and specific job requirements • Subsidizing employers for every job creation that employs for 18 months unemployed young people up to 29 years of age with permanent disabilities or military persons with disabilities, as well as young people from social care institutions.269 The subsidized period is 9 months and thereafter the employer should keep the person for another 9 months in employment. The monthly wage is 256 euro (500 BGN) for people with up to secondary education, and 281 euro (550 BGN) for those with tertiary education.270 • Labor mediators271 may apply for receiving funds for supported employment272 for each unemployed person with permanent disabilities or from other disadvantaged groups in the labor market, directed by Labor Offices, who has been employed in a non-subsidized job for 269 Article 36, paragraph 2, Employment promotion act (EPA). https://www.az.government.bg/web/files/PageFile/74/13555/zakon-za-nasyrchavane-na-zaetostta.docx 270 https://www.az.government.bg/pages/myarka-naemane-na-mladezhi-s-trayni-uvrezhdaniya- voennoinvalidi-i-mladezhi-ot-socialni-zavedeniya/ 271 Registered under EPA, Article 27, paragraph. 2, item 2, EPA. https://www.az.government.bg/web/files/PageFile/74/13555/zakon-za-nasyrchavane-na-zaetostta.docx 272 Article 30a, paragraph. 1, item 23, EPA. https://www.az.government.bg/web/files/PageFile/74/13555/zakon-za-nasyrchavane-na-zaetostta.docx 142 at least 12 months.273 EPA defines "Supported Employment"274 as a provision of assistance to unemployed persons with permanent disabilities and other disadvantaged groups in the labor market, according to their specific needs, to work in non-subsidized jobs. The labor mediators are selected based on the Public Procurement Law. For each unemployed person, employed in a non-subsidized workplace for a period of at least 12 months, the labor mediators (contractors) are provided with funds determined in NAPE for the respective year. For instance, for 2020, the amount was 358 euro (700 BGN) per mediator per month. • For each job created for unemployed persons with permanent disabilities, referred by the NEA Labor Offices, an employer is provided with a subsidy for 3 to 12 months with no obligation to retain the person after the subsidized period has ended. The subsidy is up to 75 percent of the labor cost per employee during the subsidy period. The maximum monthly wage is determined every year in NAPE and usually equals the minimum wage (332 euro (650 BGN) for 2020) unless otherwise stated. • Subsidizing employment of the unemployed with permanent disabilities, including military disabled, directed by NEA for full- or part-time employment, not exceeding 12 months.275 The subsidized period is 6 months, and the employer should keep the employee for another 6 months in employment. The monthly wage is 256 euro (500 BGN) for individuals with up to secondary education and 281 euro (550 BGN) for those with tertiary education.276 В. Supporting the inclusion of persons with permanent disabilities in employment programs, implemented by NEA The National Program for Employment and Training of Persons with Permanent Disabilities implemented by NEA is a fully subsidized program for unemployed persons with permanent disabilities who are hired for 24 months. Priority is given to persons with at least 71 percent of reduced work capacity; military persons with disabilities, and persons with sensory and mental disabilities. Priority for participation in the program is given to employers who conclude a contract to finance activities for adaptation and/or equipment of workplaces for persons with permanent disabilities and are providing access to workplace, skills development, training for professional development and other activities under the National Employment Program for Persons with disabilities.277 Program activities include identification of beneficiaries, training, and subsidized employment. The subsidy is paid based on actual worked time. The subsidy period is up to 24 months and the monthly wage is determined annually in NAPE. The monthly salary usually equals the minimum wage for all participants apart from those with higher education who get slightly higher remuneration. For instance, in 2020, the monthly wage was 312 euro (610 BGN) and for people with tertiary education 332 euro (650 BGN). Apart from the above program, in most of other NAPE programs, persons with disabilities are targeted as part of disadvantaged groups and each of these programs also includes employment or activation measures for persons with disabilities. 273 Article 43a, EPA. https://www.az.government.bg/web/files/PageFile/74/13555/zakon-za-nasyrchavane-na- zaetostta.docx 274 “Additional provisions”, EPA. https://www.az.government.bg/web/files/PageFile/74/13555/zakon-za- nasyrchavane-na-zaetostta.docx 275 Article 52, paragraph 1, EPA. https://www.az.government.bg/pages/zakoni/ 276 https://www.az.government.bg/pages/merki-po-znz-naemane-na-bezrabotni-lica-s-traini-uvrejdania/ 277 Article 44, paragraph 1. PDA. https://ahu.mlsp.government.bg/portal/page/3 143 C. Operational Program “Human Resources Development” (OP HRD) – the European Social Fund support OP HRD is another important source of financing for ALMPs, implemented by NEA and MLSP. While the regulatory framework is the same as for other ALMPs, OP HRD gives more flexibility to implement labor market services. For instance, OP HRD supports integrated services, so that there could be interventions that may simultaneously include subsidized employment, training, coaching, social and health services, and other employment support services. In some years, OP HRD provided support to as many beneficiaries as NAPE; however, it remains less stable and predictable instrument because of its dependency on the 7+2 years program cycle. For instance, during the first 2-3 years of each seven-year programming period the programs are often not ready to be launched due to administrative issues and delays. The project-based approach leads in some cases to interruption in the support to specific persons, groups, or activities. This is the case with the coaching for permanently disabled person with mental disorders; such a person needs support permanently but when a project finishes, the coaching ends as well. A possible solution could be in the integration of the rules and procedures of the NEA and OP HRD interventions. Moreover, based on the lessons learned from OP HRD, the menu of NEA interventions could be expanded to include coaching, social and health services, assessment of work capacity, etc. Good examples in that direction are two large projects implemented by NEA and financed through OP HRD: “Training and employment for youths” (15-29 years of age) with budget of 59.3 million euro and “Training and employment” (age 30+) with budget of 102.8 million euro. Both projects were planned to be implemented in the period 2015–2023. With approximately 25 million euro per year these two projects significantly complement NAPE. Both have special second components which target directly inactive and unemployed persons with disabilities. Priority is given to those who have disability degree over 75 percent. Below, we provide some details about these two projects. Both projects provide the following labor market services: • Information and referral directly to vacancies for persons from the target groups for whom the job does not require training. • Providing training to unemployed persons with permanent disabilities, including by issuing vouchers, to acquire key competencies. • Providing coaching for target groups with permanent disabilities (for up to 3 months). • Subsidizing employment of persons with permanent disabilities full- or part-time (at least 4 hours a day) in jobs falling within the scope of professions from 2nd to 9th grade of the National Classification of Occupations and Positions,278 for a period of up to 24 months. Monthly subsidy is calculated based on the monthly insurance income determined in the annual State Social Security Budget Act and differentiated per economic activity and profession.279 • Provision of one-off incentives covering the amount of six minimum wages, provided to employers who have retained an employee with disabilities for at least 6 months following the end of the subsidized period. Both projects differ in several aspects from other ALMPs. First, they provide higher subsidies based on monthly insurance income compared to NAPE’s close-to-the-minimum-wage remuneration. Second, they add coaching to the traditional trainings and subsidized employment. And third, they manage to 278 https://www.nsi.bg/sites/default/files/files/pages/Classifics/NKPD-2011_1-928.pdf 279 https://nra.bg/document?id=20749 144 ensure 5-6 years continuity of the programs’ access, because they have longer period of implementation compared to other EU programs (usually 2-4 years). In the programing period 2014-2020, OP HRD additionally financed three projects targeting labor market support to persons with disabilities. They were “Equal Opportunities”, “Active Inclusion”, and “Development of Social Entrepreneurship”. They were managed by OP HRD Managing Authority in MLSP. “Equal opportunities” program (approximately 4 million euro) was designed to be implemented by nationally representative organizations for persons with disabilities. In terms of labor market support, the program included activities such as professional orientation, motivation, psychological support, development of individual plans. However, the employment of persons with disabilities itself was not the focus of the program and just 200 people were expected to either start looking for a job or working. “Active inclusion” program (approximately 10 million euro) had more explicit labor market focus. It was designed to be implemented by different organizations such as NGOs, social service providers, labor mediators, training organizations, employers, municipalities. The main target groups were persons with disabilities, their families, inactive people, children, and elderly at risk of poverty. The main eligible activities included: • Provision of mediation services in the labor market and other employment support. • Professional information and consulting on issues related to exercising of labor and social security rights of persons caring for dependent members or persons with disabilities. • Improving access to career development services, promoting labor market participation, and restoring the employment of family members with children (including those with disabilities). • Vocational training. • Training for the acquisition of key competencies "Communication in foreign languages", "Competence in mathematics and basic knowledge in the field of natural sciences and technologies" and "Digital competence". • Workplace adaptation and equipment for persons with disabilities in case the employer hires persons with disabilities. • Activities with employers to overcome discriminatory attitudes when hiring someone from the labor market vulnerable groups, together with the provision of mediation services for employers. • Motivational and/or psychological or other type of support for the target group, according to their individual needs - counseling, medical, social, educational, and psychological support to improve their access to the labor market. • Support for finding a job and improving access to employment for persons with disabilities, including through integrated measures and the provision of supportive innovative services in the community such as social services (day care centers, personal assistants), integrated social and health care. “Active inclusion” was an innovative program, which introduced integrated support for persons with disabilities for labor market inclusion. The program aimed to include at least 500 persons with disabilities into the labor market. Persons with disabilities were one of the main target groups in the “Development of Social Entrepreneurship” program (approximately 7.5 million euro). The program was designed to be implemented by different beneficiaries such as employers, social enterprises, specialized enterprises, and cooperatives of persons with disabilities, municipalities, NGOs. Although the program was directed to strengthen social enterprises capacity, it also provided a support to different target groups 145 including persons with disabilities. However, there were no specific indicators pertaining to persons with disabilities. Activities implemented under this program were: • Psychological support and motivation to persons from vulnerable groups for inclusion in employment. • Vocational orientation, support for building working habits, assistance in finding a suitable job. • Development of individual work, therapeutic and integration plans, and their implementation. • Involvement of persons from the target groups in trainings for production/provision of specific goods or services. • Providing training to persons with ensured employment in social enterprises and specialized enterprises and cooperatives of persons with disabilities, including vocational training directly related to relevant workplaces, as well as training in key competencies “Communication in foreign languages”, “Digital competence” and “Public and civic competences”. • Coaching to newly employed people from the target groups. • Purchase of needed equipment for social enterprise, as well as the newly created jobs and, if necessary, their adaptation for persons with disabilities and/or construction works in connection with the activity of the social enterprise. • Support for employment for up to 12 months for people from the target groups employed with the respective social enterprises. “Development of social entrepreneurship” program was also an attempt to integrate different types of support leading to employment of different vulnerable groups. Together with “Active Inclusion” program, it is an example of more complex integrated programs for labor market inclusion of vulnerable groups. The results of the OP HRD projects and programs and lessons learned were not available at the time of writing of this Report. 146 Chapter 7: Disability information and data management systems In this chapter we present disability system and policy related information management systems. The most relevant are three of them. We are also discussing the availability and use of evidence-based data for disability policies development and monitoring their implementation. 7.1 Information System for the Medical Expertise The Unified Information System for Medical Expertise (UISME) of the Republic of Bulgaria is an electronic information system of the National Medical Expert Commission (NMEC), established in 2011-2013 supported by of the European Social Fund (ESF) under the Operational Program Human Resources Development (OP HRD) at NMEC as a beneficiary under the project BG051PO001-6.2.12- C001. With the establishment of the UISME, the first integrated information system of medical expertise was created in Bulgaria. It brought together Regional Files for Medical Expertise (RFME), Territorial Medical Expert Commissions (TMECs) and NMEC. The UISME encompasses, models, and automates all main processes of the medical expertise bodies related to the assessment of permanent disability (PD), temporary disability – sick leave (TD) and disability type and severity (DTS). UISME280 is established as a central register with electronic files of citizens with temporary and permanent disabilities who have undergone the relevant medical assessments and expertise. The standards for the UISME development meet the criteria that all modern information systems in Bulgaria are subject to, in response to the EU requirements for the establishment of an e-government. UISME was developed as an online system, a web-based application with three-layer architecture, working with a central database. The database management system used in the UISME is licensed under the Oracle Database Standard Edition version 11gR2. The system features an expandable architecture that allows for a good adaptation to the current needs and the ability to adjust it to future needs. It was developed on a modular principle, allowing greater flexibility and easy expandability. Developed as a technological system considering the requirements of the regulatory framework, the UISME features a flexible system for managing the access of the individual users to information, so that it matches the administrative profiles of the respective employees and their administrative rights and obligations as users in TMEC, RFME and NMEC, respectively. Access management encompasses the deployment of hierarchical access – access to the whole system, to individual modules, to specific actions in the system, etc. The UISME reflects all processes while conducting medical expertise for the assessment and reassessment of temporary and permanent disability in the Republic of Bulgaria: from the application submission to the RFME281 with the necessary documents, the creation of a medical file (MF) for each person, their referral to the respective TMEC282 through the system, the performance of medical expertise and the issuance of an expert decision, which is entered in the person's file. There are procedures to appeal the expert decision to the NMEC283 and procedures for administrative proceedings in relation to the appealed expert decision (a separate registers have been established in the UISME database for these). The record-keeping module and the intersystem mail allow tracking of all documents received and their movement in the medical expertise and fast communication among users of the UISME by the medical expertise bodies – RFME, the Regional Health Inspectorate (RHI), TMECs and NMEC. 280 The Unified Information System for Medical Expertise (UISME) is available at https://eisme.nelk.bg/ 281 Regional Files for Medical Expertise 282 Territorial Medical Expert Commission 283 National Medical Expert Commission 147 Within the UISME a separate Reference module has been created that enables system users to perform a variety of cross-references on random combinations of features of the in-system items: documents, files and records, patients, expert decisions, and tasks, using partial elements of the description of the individual features, as well as to display statistics. The reference reports in the system can extract data from individual files, as well as aggregated statistical reports on various criteria and a combination of them – based on medical diagnoses, by district, by time, by expert decision issuing authority and many others. The produced reference reports are in accordance with the current regulations in the field of medical expertise and allow for expert analyses and analyses as per the main medical expertise regulations – Rules for the Structure and Organisation of the Work of the Bodies of Medical Expertise and of the Regional Files for Medical Expertise and the Ordinance on Medical Expertise. NMEC is the primary data controller regarding the data about people with disabilities in the UISME, as stipulated in Art. 4, item 7 of Regulation (EU) 2016/679 and Art. 2, Para. 2 of the Electronic (eGovernment) Government Act.284 In this capacity it provides interested state authorities and institutions with access to data from the UISME via the RegiX Inter-registry Exchange Environment of the State Agency for Electronic Governance (SAEU). The UISME provides to all interested departments, institutions and citizens controlled online access to information on the medical expertise processes, depending on their specific interests. As the primary data controller for the UISME and pursuant to Art.3 of the Electronic Government Act, NMEC sends the data ex officio and free of charge to all administrative authorities, to the persons performing public functions and to the organisations providing public services that on legal grounds also process these data and have requested to receive them, through the RegiX Inter-registry Exchange Environment. For the fulfilment of statutory obligations, data are currently received via the RegiX Inter-registry Exchange Environment by UISME maintained in NMEC from: • personally, from the persons through their profile in the Agency for People with Disabilities (APD) as a person with disabilities under Article 82, para. 5 of the Persons with Disabilities Act, • from institutions: Ministry of Finance, National Revenue Agency, all municipalities, Ministry of Interior, Ministry of Labour and Social Policy, Social Assistance Agency, Employment Agency and other institutions "data consumers", who have been given access to the data in the medical expertise system UISME by NMEC in the capacity of primary data administrator via the RegiX Inter-registry Exchange Environment of the State e-Government Agency. The UISME is of national importance and as such it is included in the Implementation Plan of an Integrated Solution for Administrative and Social Services for Persons with Disabilities and related administrative services through the creation and management of a profile of persons with disabilities, approved in August 2018 by the Council of Ministers of the Republic of Bulgaria (Decision on item 29 of Protocol No. 31 of August 8, 2018, from a meeting of the Council of Ministers). The plan mandates the upgrading and optimisation of the work of the UISME and its link to the Information System of the APD and the integration with the horizontal eGovernment systems. The Council of Ministers decision provides for the development of new references in the RegiX Inter-registry Exchange Environment, administered by the State e-Government Agency (item 2.1.3 of the Decision), as well as for the development of new adapters for the APD information system and for the NMWC’s UISME to connect with RegiX (item 2.1.3 and item 2.1.4 of the Decision). As a priority task, it is envisaged to upgrade NMEC’s and APD’s information systems so that they can provide internal electronic administrative services to people with disabilities through RegiX (item 2.1.5 of the Decision). The decisions under item 29 of Protocol No. 31 of August 8, 2018, from the Council of Ministers meeting, assigned the following tasks: 284 https://www2.e-gov.bg/en/about_us 148 • Upgrading NMEC's and APD's information systems with new functionalities related to the work with profile of the disabled people. Extending the data coverage by including data from services at the Ministry of Health, NHIF, NSSI, MES, ASA, Employment Agency, NRA, Civil Registration and Administrative Service Directorates, municipalities, etc. (item 2.2.1 of the Decision). • Migrating data to the UISME from existing old systems at the RFMEs and TMECs (item 2.2.4 of the Decision). Within its powers and the allocated funds from the state budget, NMEC implements a large part of the tasks assigned by the Council of Ministers. Pursuant to items 2.1.3, 2.1.4 and 2.1.5 of the Council of Ministers decision from 2019, a connection was established with the RegiX Inter-registry Exchange Environment, where NMEC maintains three types of reference reports: a report on all expert decisions per person, a report on all expert decisions issued over a specified period and a report on the last expert decision per person, which can be accessed by stakeholders as per Art. 1, para. 1 and 2 of the Electronic Government Act. In assessing the requests for access to data in the UISME, NMEC, as the primary controller of personal data for disabled persons, shall determine the legality, legitimacy, and appropriateness of the requested access for each applicant. In accordance with Art. 108a, para. 6 of the Health Act and Art. 3 of the Electronic Government Act, and in pursuance of item 2.2.1., a certain amount of data in the UISME can be accessed through RegiX by several state bodies and institutions (ASA, APD, MLSP, NSSI, NSI, etc.), while exercising their duties concerning persons with disabilities. In connection with the agreement signed between NMEC and ADP on May 25, 2015, for the provision of data from UISME, the information systems of ADP and UISME were linked directly. In October 2020 the Ministry of Health has put into operation a new Information System for Control of Medical Expertise (ISCME)285, commissioned on 05.12.2018 by the Ministry of Health and the Information Services, which facilitates the assessment and reassessment process of persons only in terms of permanent disability. It allows electronic access to persons who have undergone, are currently undergoing, or have applied for medical expertise. The purpose of the system is to assist all participants in the disability certification process. It integrates NMEC, TMEC and RFME and, thus, links the data from different administrative structures and creates a central register of data for all citizens who have passed through TMEC and NMEC. According to a letter from the Minister of Health, the new requests for assessment and reassessment of permanent disability and its type and severity should be initiated in the ISCME, while any already started/ongoing procedures should be completed in UISME. Both systems – the UISME and the ISCME – are currently in operation and assessment and reassessment of a permanent disability are handled in one of the systems. Since the new ISCME lacks a module for the assessment of temporary disabilities these are performed only in the NMEC's UISME. The ISCME covers all processes related to assessment and reassessment of disability and incapacity for work. This is a web-based system accessed by all users with a certified electronic signature, which provides and exchanges real-time data and stores information for all persons who have undergone a NMEC or TMEC assessment. ISCME is connected to the Civil Registry and the Administrative Services in order to verify the data of each person, requesting an assessment or reassessment, as well as to the Bulgarian Medical Association in order to obtain data on qualification and expertise of the TMEC and NMEC members. It enables centralised storage of data on medical expertise, sending electronic notifications with the possibility of electronic delivery to the person and stakeholders, web-based 285 The Information System for Control of Medical Expertise https://ibd.mh.government.bg 149 interface for medical consultation protocol by the Medical Advisory Committee, application for certification/expert decision by the person or stakeholders, automated electronic transmission of expert decisions and data to stakeholders and monitoring the activity of all structures involved in the issuance of expert decisions. There is no module to process temporary disabilities and a separate system – the Information System for the Assessment of Temporary Disability, which is under development and will be put into operation in due course. Monitoring of processes and reports: Individual users' access to information is controlled through hierarchical access to individual modules and specific activities and matches the administrative profiles of employees, their administrative rights, and obligations as users in TMEC, RFME and NMEC. Beneficiary's pathway in ISCME Logging in. Clients' access to the ISCME portal is provided following an authentication with a certified electronic signature. Medical records. Upon identifying herself/himself in the system, the person, applying for an assessment or reassessment of disability can retrieve her or his medical records from the home screen or from the list menu. The medical records includes protocols and guidelines (“instructions”) from the Medical Advisory Committee, submission of an application, applications, expert decision(s) by TMEC or NMEC, complaints and attachments (see screenshot 4, ISCME – medical record). In the Certified Person field, the personal data are loaded by default upon logging in using certified electronic signature. When a person logging in with a certified electronic signature is a proxy or a parent of a Certified Person, the name of the person they represent should selected from the menu. Medical Advisory Committee guidelines and protocols. If a Direction or a Protocol has been issued by the Medical Advisory Committee, the person may apply electronically (see screenshot 5, Guidelines and Protocols by the Medical Advisory Committee) Application. The application is organised in several steps. The first, "Data about the Certified Person", displays data about the person loaded from the certificate and the data entered in the directions or protocols by the Medical Advisory Committee. After updating their unique identification number (if needed), phone number, email, and mailing address, or continuing without updates, the user proceeds to the next step, “Data about the sender". Any edits can be done via the "Profile" menu. The application is filled in during the next step "Declaration". The reasons for the assessment or reassessment are selected. This is where assessment or reassessment is chosen. Through interactive fields, the persons complete data on whether they receive a pension, type of insurance and place of work. In the next step "Supporting documents", the person attaches, i.e., uploads medical diagnostic documents, medical records, etc. The system generates “success” messages whenever a document is attached, and the file appears on the list of attachments. To complete Application, the system generates a pdf file, which should be signed with an electronic signature by the person. The system generates a “success” message after the document has been successfully signed and saved. It is not clear how the validity of the uploaded documents and updated information is cross-checked and verified and why the document flow is not automatic from the Medical Advisory Committee. Applications. After the Application is successfully signed with an electronic signature, the system leads the user to the "Applications" – a list menu with all submitted applications. This is where the applicants can track their application status. Expert decisions. After the TMEC or NMEC issue their Expert Decision, it becomes available in the "Expert Decisions" menu and can be viewed, printed, or used to launch an appeal. 150 Appeals. Upon reviewing an expert decision, the user can file a complaint through the system. After entering the necessary information about the reason and nature of the appeal, a pdf file is generated, which must be signed with an electronic signature (see screenshot 6 ISME – Complaint screen). Attached Documents. All scanned documents attached to the Medical Advisory Committee's directions or protocol, the application, the TMEC/NMEC decision or complaint are available here. The System supports "Messages" that display information regarding messages sent to the Certified Person or to the representing person regarding any action related to the Certified Person or the person acting as proxy (see screenshot 7 ISME – Messages screen). The calendar contains all dates from the applicant’s record – submission date of the application, TMEC date, issuance date of the TMEC decision, submission date of the appeal against the expert decision, etc. When the user selects the "Benefits" menu, up-to-date information is displayed about the benefits received by the certified persons. Account. Initially, the user will see her or his national ID and e-mail address, verified by a certified electronic signature. The remaining data are filled in by the person or are filled in automatically if the person has already applied through the Regional Files for Medical Expertise and in case an employee has already created a medical record. All data except the ID number can be edited. It is not clear how the edits are verified and approved. For instance, the unique ID number is linked to the date of birth, gender, etc. In principle, changing a date of birth that would then be different from the one recorded in the ID file, should not be allowed. The system displays information about the submitted Applications for access to the Medical Record by the Applicant or Legal Representative or Proxy and provides an opportunity to submit a new one. Personal data is filled to grant the user access to the relevant medical records. The fields contain details of the person for whom the medical documents will be submitted and tracked in the file. The completed applications and the section for attachments, such as power of attorney or other documents certifying the need for access to the medical file of the Certified Person, are displayed. Attaching a document is required. After confirmation, the Application is signed with an electronic signature and a message about the processing is received in "Messages". Institution’s pathway in ISCME After successfully logging into ISCME, basic information necessary for the processing of data according to the user's role in the system is displayed on the home screen. The numbers in the sections show the number of data to be processed and the attached sections show that there are unprocessed documents. From the list of applications pending processing, the TMEC selects a specific application for processing (Screenshot 1 ISCME – Home screen with basic information). Upon the selection of an assessment site, the date and time are selected according to the availability of TMEC (Screenshot 2 – List of applications pending processing). When the "Book an appointment" button is selected, the system generates a warning message, after confirming the scheduled date and time of TMEC, the appointment is successfully recorded, and the system generates a message that is sent to the applicant. The appointment at the TMEC can be seen in the List of submitted applications pending processing. If additional documents are needed, the TMEC employee indicates which documents need to be added to the application and returns it to the Regional Files for Medical Expertise. After the TMEC meeting, the TMEC employee enters the information related to the TMEC decision in the applicant's file. The fields in grey contain information about the Certified Person retrieved from 151 her or his application that cannot be edited; other data fields remain to be filled in by TMEC. The successfully recorded data display information about the TMEC issuing the Expert Decision. In the field below the data on the TMEC, the number of the Expert Decision is indicated. It is automatically assigned with the Decision's issuance. Also shown there is the number and date of the meeting of the TMEC (Screenshot 3 ISCME – Issuing a Medical Expert Decision). The Decision can be printed for signing by the members of the Commission or signed with a certified electronic signature by all members and the Chair of the Commission. The TMEC transmits to the certified person the issued expert decision; then the system generates a success message for the record and the status of the medical expertise decision changes to "Delivered/Served". With UISME and ISCME the system for medical certification of disability and incapacity for work is fully automated and has a great potential to manage and control medical expertise. The system is new, and as with all such systems, it will take time to fix "bugs" and have a smoothly running system. Although there is excellent potential, for example to monitor TMEC decisions and detect any deviations, there are some issues that need to be addressed. The first is having a fast internet connection. Without one, attaching files and sending them would be almost impossible. The second issue is the computer literacy. Applying online can be challenging, especially for older people, who make up almost 60 percent of people with disabilities and reduced work capacity in Bulgaria. Even if everyone has a personal computer, which is not the case, scanning documents and attaching them is not the most intuitive process. Thirdly, the verification of the data entered, and the attached documents is mandatory, but it is not clear how it is done now. One way of solving these problems would be the introduction of an automated referral system linking service doctors and Medical Advisory Commissions to the TMEC, which would also include all relevant medical records (in case of reassessment, the files and documents from previous evaluations can be retrieved from the relevant RFMEs). The person should be informed about the referral, and she/he should be able to access her/his file and check the information for accuracy and up-to-datedness and to request corrections. Another very important issue, critical for the monitoring and control functions, and for the overall disability information system is that all diagnoses should be coded using the WHO International Classification of Diseases. Similarly, the TMEC/NMEC decisions should contain fields in which the basis for disability decision was made would be explained in detail. 7.2 Integrated Information System at the Social Assistance Agency The integrated information system (IIS) of the Social Assistance Agency (SAA) was designed and implemented in 2016. The scope of automation includes the operational activities related to social assistance, social services, and child protection in all SAA organizational units. Electronic incoming logs are fully used to reduce the time for servicing customers of SAA and to introduce the principle of a "One stop shop". The IIS is serving in real time 4,800 employees of SAA across the country. All administrative services provided by the territorial divisions of the agency are performed through the system. IIS generates data for all operational, management and statistical reports. The system is constantly updated to respond to the requirements of the latest legislation and to the needs of consumers and a wide range of customers. IIS has the following functional subsystems: Files of persons; Social assistance; Social services; Child Protection; Input/Output Interfaces to other information systems; and System administration (Figure 7.1). All structures of SAA work with IIS: Headquarters, Regional Directorates for Social Assistance, Directorates for Social Assistance and Outsourced Jobs, ensuring centralized collection, storing and use of information. The system collects, processes and stores data on applicants regarding their health status, related persons, submitted applications, current address, identity document and income in compliance with the Regulation (ЕС) 2016/679 on the protection of individuals regarding the 152 processing of personal data and on the free movement of such data and repealing Directive 95/46/EО (Figure 7.2 and Screenshot 6 – SAA Person – General Information in IIS). Figure 7.1: Social Assistance Agency Functional Subsystems IIS performs about 58 different automated work processes related to: • acceptance, distribution, and operational work on applications, • determination of the amount of aid - automatically and with the possibility of manual adjustment, if necessary, • generating and retrieving decisions, • generating and displaying worklists, payrolls, and files for other information systems, • entry, changes, and deregistration from normatively regulated registers, • reports divided into groups by purpose and modules of the system. Figure 7.2: Social Assistance Agency – Individual Data Model 153 Technical Specification and Logical Architecture Considering a heavy workload of the SAA IIS, different types of data processing, and the volume of data received, sent, or exchanged with other institutions, and the need for future growth, the logical architecture provides necessary system reliability, security, scalability and hardware optimization (Figure 7.3). A server is used for data management; a database management system is located on the server Oracle Database 11.2 with data being stored on a disk array.286 If necessary, future configuration expansion is possible with the help of Real Application Cluster (RAC). RAC architecture ensures reliable operation of the database allowing load balancing between available servers: in case one of them is not available, the rest of the servers will take over the work without causing the system outage. Backup servers and disk arrays ensure that an up-to-date copy of the database and application is always available - in case of an outage of the main server(s) the data array system will continue to function to prevent data loss. The backup of the database is maintained with the help of the Oracle Recovery Manager by copying the database files and log files regularly. Figure 7.3 : SAA ISI – Logical Architecture 286 A disk array is a disk storage system that contains multiple disk drives. It is differentiated from a disk enclosure, in that an array has cache memory and advanced functionality, like RAID, deduplication, encryption and virtualization. 154 Data exchange with other systems The SAA IIS regularly receives electronic data from several external information systems. Incoming interfaces: data from external systems generated in text files and uploaded by an administrator into the IIS: • National Social Security Institute: IIS receives data on cash benefits paid and state social security, unemployment benefits and pensions. • National Employment Agency: IIS receives data on registered unemployed persons. • Ministry of Regional Development and Public Works: IIS receives data on deaths for the current and the previous month. • Ministry of Education and Science: IIS receives data on students/pupils enrolled during the school year, data children's absences and children, who are not attending kindergarten or school. • Road Infrastructure Agency: IIS receives daily information about provided electronic vignettes. Although some other external databases may be missing, the most critical are the UISME/ISCME. The SAA should receive daily data from the UISME/ISCME, including TMEC/NMEC decisions, but also data on sick leave extensions. Once operational, the Sick Leave Information System must also submit the relevant information to the SAA IIS. Moreover, the link should enable automatic referral for assessed/re-assessed persons to SAA for PDA INA. Output interfaces: IIS data generated in text files and sent to administrators of external information systems: • Heating companies • Electricity companies • National Revenue Agency • Banks • Bulgarian Post • The Accounting Department of the Social Assistance Agency. Data provided to external systems by SAA IIS: • National Legal Aid Bureau. Information about persons receiving benefits, aid for heating and orders issued for social services (maternal and infant wards, specialised institutions, and social services of the resident type). • Reference Implementation of National Application (RINA)287. Information about persons with benefits granted. • Agency for People with Disabilities. Information about people with disabilities (individuals can check their personal information on the APD website under profile of a person with disabilities). • National Social Security Institute. Daily reporting on the status of applications for monthly child benefit (in case they are not entitled to a deceased parent's survivor's pension). • Social service providers registry288. Public register of all social service providers holding a valid certificate. 287 Electronic exchange of insurance information between Bulgaria and the EU. https://ec.europa.eu/inea/en/connecting-europe-facility/cef-telecom/2016-bg-ia-0031 288 The register of social service providers is available at: https://asp.government.bg 155 • Automatic information exchange through RegiX with the Ministry of Interior – vehicle information by registration number. System referrals and registers Access to data and features in the system is granted by organization, function, and regulatory criteria. System users use personal data for authentication, which is valid for a certain period. User’s personal data (password) is required to be changed periodically. Predefined reports are grouped by purpose and system modules. Depending on the level of access defined in the system, users may not be able to see all available reports in the system. SAA IIS maintains standard and interactive reports. Standard reports display lists with static predefined columns with basic functionalities. Interactive reports include a range of functionalities to choose from and data can be arranged by columns, filters and grouped in the report; a user can save the report with selected criteria as a template to use it later in the interactive reporting. Lists with data can be filtered by different criteria predefined in the context (module, organization or other), defined by the user’s access, as well as filters selected by the user. In the same way data in columns in reports can be visible or not, depending on the user’s permissions and the page context. Predefined reporting forms exist in the system. They are created according to the requirements for regular reports to summarize data with options to select date range and filters from predefined criteria and filters. SAA IIS is a good example of reports that can be generated using the data the SAA collects in the discharge of its functions. Other systems, in particular UISME/ISCME should follow this practice example. The SAA data flow is presented in Figure 7.4. Figure 7.4: SAA – Administrative process and data flow Administrative processes (see also Figure 7.4) 156 Applying. Completed Application-Declaration for the preparation of an individual needs assessment289 and a self-assessment form290 are submitted to the Social Assistance Directorate at the current address of the applicant. When applying for targeted assistance for technical aids (assistive and medical devices, equipment, etc.) a relevant protocol from MAC/TMEC must be submitted in the original form. Ideally, all documents should be available to SAA through an inter-agency electronic exchange of data. The application can be submitted: 1) in person (presenting an identity document for a reference; 2) through a licensed postal operator with attached original documents; 3) electronically through the Secure electronic delivery system (https://edelivery.egov.bg). For this, it is necessary to have a Personal Identification Code issued by the National Social Security Institute or a qualified certificate for qualified electronic signature or electronic identity. After the registration and identification in the system for secure electronic service, an electronic form for a specific service is downloaded from https://egov.bg. Acceptance and registration of an application. Authorized employees can accept applications and complete registration in the information system: A reason for application is selected from the entry log from the dropdown menu along with the channel the application has come through. If personal Identification number is available in the database, it can be entered in the system to autofill the full name and permanent address in the fields (see Screenshot 8 – SSA Registration of an Application in IIS). There is a functionality to manually check permanent address data in the National Population database via data exchange environment RegiX.291 The remaining fields in the application are filled by a person registering the application or by selecting answers from the SAA system’s menu. The employee registers the application in the information system and assigns a registration number to the application. All branches of SAA have an Administrative Services Center and unique application numbers. Distribution of the application-declaration. Head of the department or an employee authorized by the director of the Social Assistance Directorate, from the initial screen of the system distributes the received applications among the social workers in a specialized department for further processing, according to the established organization. Electronic processing of the application-declaration. The social worker leading the specific case enters in the information system all data declared by the person in their Application-Declaration for preparation of the individual needs assessment, as well information from the Self-Assessment Form. In case the data is available in the system, it is loaded automatically. Checking for omissions and/or irregularities. After having received the application, the responsible social worker examines the documents. If some data is found missing, the applicant is informed in writing and given 14 days to provide the missing information. Checking and verifying the declared data and requesting the necessary information ex officio. The social worker leading the case ex officio verifies the declared information in the registers of the primary data controllers provided through the RegiX inter-registry exchange environment (e.g., data from the Ministry of Regional Development and Public Works, National Medical Expert Commission, National Revenue Agency, National Social Security Institute, etc.). Preparation of the individual needs assessment. See Chapter 4 and Annex 5. 289 Application-Declaration for the preparation of an individual needs assessment. https://asp.government.bg 290 A self-assessment by a person with a disability. https://asp.government.bg 291 RegiX Info at: http://regixaisweb.egov.bg. 157 Preparation of a motivated proposal. The social worker leading the case initiates a proposal for granting or refusing requested assistance in the information system, as well as on paper. Preliminary control is performed to ensure compliance of the proposed granting or refusal of requested assistance with normative regulation. The head of the department or an authorized person by the director of the Social Assistance Directorate compares the electronic file with the completed file on paper and reflects the results in the system by confirming the proposal of a social worker (in IIS and on paper). A paper form for performed preliminary control for legality is filled in. In case of established omissions, the file is returned to the social worker for corrections, and this is reflected in the preliminary control sheet. Issuance of an individual administrative act (order) for granting or refusing to grant the requested benefit(s) is performed by the director or an officially authorized employee, who generates a draft of an individual administrative act (order) through the system, and prints and signs it. Notification to the applicant about the issued individual administrative act (order) declining to grant requested assistance. The social worker notifies the applicant in writing within 7 days from the issuance of the order (by certified mail with a return receipt). Payment of benefits. The system administrator generates and prints work lists; the social worker checks the consistency between the personal data and the amount of assistance in the work list and the compiled dossier. In case of errors, the work lists, accompanied by the files of the persons for whom corrections have been made, is submitted to the IIS administrator for reflection in the system. The administrator automatically generates the statement from the IIS payrolls. The statement is printed and signed responsible officials, after which the files for banks and lists for the Bulgarian Post are generated. Appeal of the issued individual administrative act and issuance of a decision. The applicant may appeal in accordance with the provisions of the Administrative Procedure Code within the statutory period. Overall, SAA has a sophisticated information system. As any system, it needs constant renewal and development as demands placed upon it and environment in which it operates evolve. In that sense, the introduction of the individual needs assessment in 2019 requires a much tighter connection and exchange of information with the UISME/ISCME, so that all information from the certification of disability and work capacity is automatically populated into the individual needs assessment files. Furthermore, since SAA, based on individual needs assessment issues decisions on eligibility for support measures administered by SAA, as well as referrals to social services, personal assistance and technical aids, a feedback information on the receipt of those, in addition to information already acquired from the Social Security Institute and others, will enable SAA and other government bodies a full profile of each person with a disability, including up to date information on support she or he is receiving. 7.3 Information system of the Agency for People with Disabilities The Agency for Persons with Disabilities, an executive agency of the Ministry of Labor and Social Policy operates the Information System for Persons with Disabilities (see Chapter 2). The System comprises: • Register of persons with disabilities, • Register of programs for people with permanent disabilities, • Register of specialized enterprises and cooperatives of people with disabilities, • Register of certified entities providing technical aids (transferred to the Ministry of Health). 158 The information system is built in a modular way that allows for upgrading and expanding. The system allows data import and data exchange with external information systems for collecting personal information about persons with permanent disabilities and their socio-economic status: • The National Medical Expert Commission, the Territorial Medical Expert Commissions, the Medical Advisory Commissions: Information on certified and re-certified persons with disabilities. • The National Health Insurance Fund: Information on the health status of persons with disabilities. • The National Social Security Institute: Information on persons with disabilities receiving benefits, allowances, and pensions in case of disability and temporary reduced work capacity (sick leave) under the Social Security Code. • The National Statistical Institute, the Social Assistance Agency, and the National Employment Agency: Information on the socio-economic status of persons with disabilities • The Social Assistance Agency and the State Agency for Child Protection: Information on children with disabilities, including the type and degree of disability, support measures they receive, etc. • The Ministry of Education and Science: Information about educational attainment and qualification degrees of persons with disabilities. • The General Directorate "Civil Registration and Administrative Services" at the Ministry of Regional Development and Public Works: Information on civil registration of persons with disabilities. For this purpose, all necessary interfaces for automated data exchange with the National Health Insurance Fund, National Social Security Institute, Social Assistance Agency, National Revenue Agency, National Medical Expert Commission and National Employment Agency have been developed. As a result, the information system of Agency for People with Disabilities is integrated with the horizontal systems of the State e-Government Agency. With the developed profile of people with disabilities, the information system of Agency for People with Disabilities has been upgraded with new functionalities to provide information and expand the range of data. The inter-agency exchange of data is carried out in compliance with requirements of the Electronic Government Act and Regulation (EU) 2016/679 on the protection of individuals regarding the processing of personal data and on the free movement of such data and the cancellation Directive 95/46/EC. Online access to the Profile of Persons with Disabilities The Agency for People with Disabilities through the Information System for People with Disabilities maintains the profile of each disabled person. In 2018, a General System Solution for Administrative and Social Services for People with Disabilities and Related Administrative Services was developed, through the creation and management of a “Profile of Persons with Disabilities”. The Profile gives access to data provided by the National Health Insurance Fund, the National Social Security Institute, the Social Assistance Agency, the National Revenue Agency, the Employment Agency, the Ministry of Education and Science services for people with disabilities, etc. The profile is designed for persons with disabilities to be informed about the personal data that the institutions - primary data controllers, maintain about them. It is available through the web interface of the Secure Electronic Service System.292 The criterion for access is a certified disability by 292 Secure Electronic Service System at https://edelivery.egov.bg. 159 TMEC/NMEC. The profile allows verification of personal data, as well as updating the information for contact with institutions - primary data controllers. There is a function in the Profile, which informs about the possibility to apply to NMEC, in case of a need to update the data about the person in the information system of the NMEC electronically. To help users, a Guide for working with the Profile of Persons with Disabilities was developed and published.293 Public registers294 are available on the official website of the Agency for People with Disabilities. However, the website has no statistics from the Register of Persons with Disabilities – the register, as noted above, contains comprehensive data on persons with disabilities in Bulgaria and using the database in an anonymized form to produce a range of statistical reports would provide empirical evidence for design, implementation and monitoring of disability policy in Bulgaria. Similarly, there are no analytical reports on persons with disabilities published on the Agency’s website either. 7.4 Key Messages Bulgaria has several information systems relevant for disability system and policies, including: (i) the information system for medical expertise that automates all processes related to medical expertise; (ii) the information system of the Social Assistance Agency that automates all of its business processes, including the complex individual needs assessment; and (iii) the information system for persons with disabilities housed by the Agency for Persons with Disabilities of MLSP that collates all information on persons with disabilities to create a comprehensive profile of each person with a disability; (iv) information systems of the Health Insurance Fund and the Ministry of Health; (v) information system of the Social Security Institute; (vi) civil registry information system; etc. For these report, we have looked at the first three. Important processes concerning disability system and policies are automated, including certification of disability, individual needs assessment, application for, processing and delivery of many social assistance benefits, etc. There is a significant exchange of information between various information systems, making the client journey and work of officials easier and creating a possibility for strong reporting and monitoring of policy implementation. The system(s) are built in such way that manual data entry is allowed as well, which is pertinent to persons who lack access to internet or are not proficient in the use of web-based applications. Yet, some important processes are not automated, such as those related to sick leave. More importantly, different disability system and policy relevant information systems are yet to be fully integrated. By integration, we mean that people should not be repeatedly asked to submit copies of various documents (TMEC decision, medical documents, etc.) – these should be available in/retrieved from the information system. Personal information from the civil registry should be automatically retrieved and populated into relevant blanks when persons interact with the system. The referrals to benefits and services should be automatic too. For example, once a person has been issued a TMEC decision, she/he should be automatically referred to SAA for a needs assessment with all relevant documents. Similarly, all MAC documents should follow the person when the person is referred for a medical expertise. The persons in question should be able to see her/his electronic file and flag incorrect or missing information, but she/he should not be asked to provide copies of documents. Finally, the potential of the Register of Persons with Disabilities comprising their comprehensive individual profiles is yet to be realized to provide much needed, up-to-date data for evidence-based 293 Guide for working with the Profile of People with Disabilities at https://ahu.mlsp.government.bg. 294 Public registers at https://ahu.mlsp.government.bg/home/. 160 disability policies. Despite the existence of this Register, data on disability in Bulgaria is not easy to find and one must search different sources and institutions to compile even a basic set of data needed for a simple description of disability system and policies, let alone a more sophisticated statistical analysis. But the data exist in the Register, and if presented in an anonymized format it would be a treasure trove of data for research and studies and evidence-based policy making. It only needs to be made available to the public at least through: (i) a standardized set of tables that should be posted on the APD/MLSP website; (ii) analytical reports based on the data, and (iii) an anonymized data base made available for analyses to academia, researchers, and policy makers. We thus recommend: • Rapid completion and deployment of the information system for sick leave, which should be tightly integrated with other relevant information systems (Regional Health Files, ISME, SAA, SII, NHIF, etc.). • A tighter system integration and automatic exchange of real-time information on persons with disabilities including MACs, TMECs/NMEC, Regional Health Files, Ministry of Internal Affairs, Ministry of Regional Development and Public Works, SSI, NHIF, SAA, etc. • Ensure that channels for information exchange fully comply with the General Data Protection Regulation. (GDPR). • Introduction of two-factor authentication (2FA) for identification in the system. • Introduction of electronic signature for all documents. • Establish a set of tables from the Register of Persons with Disabilities to be regularly published on the website of MLSP/APD, prepare and publish an analytical report based on data and make the micro data in an anonymized format available to academia, researchers and policy makers. Screenshot 1 ISCME – Home screen with basic information 161 Screenshot 2 ISCME – Processing Application List Screenshot 3 ISCME – Issuing a Medical Expert Decision 162 Screenshot 4 ISCME - Medical Record Screenshot 5 ISCME – Guidelines and Protocols from the Medical Evaluation Committee Screenshot 6 ISCME – Screen showing filing a complaint 163 Screenshot 7 ISCME – Screen showing Messages Screenshot 8 ASA – Application Registration in the IIS Screenshot 9 ASA – Individual – General information in IIS 164 ANNEX Annex 1: Disability Data ADMINISTRATIVE DATA - GENERAL DISABILITY Table A.1: Persons with Disabilities in Bulgaria 2017 -2019 2015 2016 2017 2018 2019 Population (Source: National Statistical 7,153 784 7,101,859 7,050 034 7,000,039 6,951,482 Institute) Persons with certified disability (>50%; 718,142 719,470 721,112 769,494 753,204 source APD) Share of persons with certified disability 10.0% 10.1% 10.2% 11.0% 10.8% in general population Table A.2: Persons with disability by age group 2017 -2019 2017 2018 2019 Children and young adults (0-20 years) 30,438 26,558 25,727 Adults (21-65 years) 257,195 276,476 288,025 Seniors (over 65 years) 429,251 432,879 439,452 Total 716,884 735,913 753,204 In % of the total population with disability 2017 2018 2019 0-20 4.2% 3.6% 3.4% 21-65 35.9% 37.6% 38.2% 65+ 59.9% 58.8% 58.3% Total 100% 100% 100% Source: Agency for Persons with Disabilities (APD) Table A.3: Severity of disability by age groups (2019) >90% (very severe) 70-90% (severe) 50-70% (moderate) Total 0-18 6,728 8,803 15,065 30,596 18-20 696 753 1,263 2,712 21-65 58,959 110,531 113,634 283,124 65+ 130,197 211,624 94,951 436,772 Total 196,580 331 711 224,913 753,204 Source: APD 165 Table A.4: Share of persons with disability by severity of disability (2017-2019) 2017 2018 2019 Very severe (over 90%) 306,693 319,196 186,294 Severe (70-90%) 293,045 326,577 321,231 Moderate (over 50%) 121,374 123,721 245,679 Very severe (over 90%) 43% 41% 25% Severe (70-90%) 41% 42% 43% Moderate (over 50%) 17% 16% 33% Source: APD ADMINISTRATIVE DATA – MEDICAL EXPERTISE Table A.5: Disability assessment - applications and certifications (2016-2019) 2016 2017 2018 2019 Applications for (re)certification at RFME (Source: MOH) 167,605 172,650 163,390 163,670 Persons who received expert decisions for permanent disability (>50%) 162,220* 156,758* 151,113* 159,551 of which 1st time certification 52,264 48,388 48,292 49,587 Source: MH Annual Reports; National Center for Public Health and Analyses (NCPHA) *Excluding children Table A.6: Annual number of persons having received expert decision on permanent disability for the respective year by age groups (2005-2019) 2005 2010 2015 2016 2017 2018 2019 0-16 - - - - - - 12,812 16-19 3,429 2,838 1,962 2,760 2,880 2,788 2,407 20-39 21,951 20,054 18,725 17,921 17,127 16,285 16,025 40-59 112,129 101,306 93,399 91,149 89,291 86,120 82,881 60+ 91,199 55,683 69,718 63,315 60,111 60,635 65,978 Source: NCPHA Table A.7: Annual number of persons, having received expert decision (1 st time and consecutive) on permanent disability for the respective year by age group and gender (2019 and 2010) 2019 Men Women 2010 Men Women 0-16 years 5,186 7,626 0-16 years no data no data 16-19 years 1,460 947 16-19 1,642 1,196 20-39 years 8,637 7,388 20-39 10,781 9,273 40-59 years 39,981 42,900 40-59 47,214 54,092 60+ years 36,963 29,015 60+ 31,536 24,147 Source: NCPHA 166 Table A.8: Persons with (re)issued expert decision during the year by severity of disability and gender (2019 and 2010) 2019 Men Women 2010 Men Women very severe (TMEC >90%) 18,817 15,846 very severe (TMEC >90%) 20,330 16,913 severe (TMEC 70%-90%) 25,814 22,175 severe (TMEC 70%-90%) 32,390 29,785 moderate (TMEC 50%-70%) 33,097 32,680 moderate (TMEC 50%-70%) 32,925 34,151 mild/no (<50%)* 9,313 9,549 low (<50%) 5,528 7,859 Source: NCPHA * ”Mild/no” in Table A.8 means that disability is not permanent (as defined in the PDA) and it is assessed at the degree <50%; it does not give rights to benefits and services. Table A.9: Children with (re)issued expert decision during the year by severity of disability and gender (2019 and 2010) 2019 Men Women very severe (TMEC >90%) 954 1,394 severe (TMEC 70%-90%) 1,212 1,819 moderate (TMEC 50%-70%) 2,339 3,404 Mild/no (<50%) 681 1,009 Table A.10: Persons with (re)issued expert decision during the year by age groups and severity (2019) 2019 Very severe Severe Moderate Low (<50%) Children (0-15) 2,348 3,031 5,743 1,690 Working age young (16-29) 2,034 5,030 3,047 1,031 Working age middle (30-49) 6,164 17,789 17,805 5,993 Working age senior (50-59) 12,494 28,310 28,243 9,569 (Pre)retirement (60+) 37,902 35,523 13,181 4,593 Table A.11: Persons over 16 years old with (re)issued expert decision during the respective year by severity of disability (2005 – 2019) 2005 2010 2015 2016 2017 2018 2019 very severe (TMEC >90%) 58,594 37,243 37,500 35,147 33,103 32,150 34,663 severe (TMEC 70%-90%) 86,652 62,175 61,161 58,628 56,542 51,929 47,989 moderate (TMEC 50%-70%) 62,276 67,076 70,135 68,445 67,113 67,034 65,777 mild/no (<50%) 21,186 13,387 15,008 12,925 12,651 14,715 18,862 Source: NCPH 167 Table A.12: Persons older than 16 years with (re)issued expert decision (for permanent and long-term disability) during the respective year by duration of the certificate (2015-2019) Total number 2005 2010 2015 2016 2017 2018 2019 One year 28,476 31,765 29,834 29,339 27,401 28,416 30,876 Two years 54,492 45,770 44,983 42,274 40,585 38,185 36,953 Three years 94,967 66,509 70,112 70,660 72,161 69,429 64,439 Lifetime 50,773 35,837 38,875 32,872 29,262 29,798 35,023 Total 22,708 179 881 183,804 175,145 169,409 165,828 167,291 Percentage shares 2005 2010 2015 2016 2017 2018 2019 One year 12% 18% 16% 17% 16% 17% 18% Two years 24% 25% 24% 24% 24% 23% 22% Three years 42% 37% 38% 40% 43% 42% 39% Lifetime 22% 20% 21% 19% 17% 18% 21% Source: NCPHA Table A.13: Persons over 16 years old with (re)issued expert decision during the year by duration of the certificate and by severity (2010; 2019) Very Low Very Low 2019 severe Severe Moderate (<50%) 2010 severe Severe Moderate (<50%) One year 6,664 9,698 11,558 2,956 One year 7,434 9,992 12,512 1,827 Two Two years 5,839 9,277 15,576 6,261 years 4,375 14,525 21,986 4,884 Three Three years 8,076 20,108 29,191 7,064 years 9,838 24,934 26,504 5,233 Lifetime 14,084 8,906 9,452 2,581 Lifetime 15,596 12,724 6,074 1,443 Source: NCPHA Table A.14: Persons over 16 years of age having received expert decision for permanent disability for the first time by main groups of diseases (2010; 2019) 2019 2010 A00-B99 Certain infectious and parasitic diseases 336 771 C00-D49 Neoplasms 13,666 11,489 D50-D89 Diseases of the blood and blood-forming organs + immune mechanism E00-E89 Endocrine, nutritional, and metabolic diseases 2,534 4,407 F01-F99 Mental, Behavioral and Neurodevelopmental disorders 2,656 3,089 G00-G99 Diseases of the nervous system 1,681 2,128 H00-H59 Diseases of the eye and adnexa 1,702 1,804 H60-H95 Diseases of the ear and mastoid process 619 798 I00-I99 Diseases of the circulatory system 14,383 21,686 J00-J99 Diseases of the respiratory system 827 888 K00-K95 Diseases of the digestive system 927 1,139 168 M00-M99 Diseases of the musculoskeletal system and connective tissue 4,722 4,322 N00-N99 Diseases of the genitourinary system 1,021 1,173 Q00-Q99 Congenital malformations, deformations, and chromosomal 231 abnormalities 124 S00-T88 Injury, poisoning and certain other consequences of external causes 1,571 2,368 Other classes of illnesses (probably L, O, P, R, U, V, Z) 230 309 Source: NCPHA Table A.15: Persons over 16 years of age having received expert decision for the first time (incl. <50% severity) by main group s of diseases (2010- 2019) 2019 2018 2017 2016 2015 2010 2005 A00-B99 Certain infectious and parasitic diseases 394 485 519 545 698 815 1,092 C00-D49 Neoplasms 13,802 12,037 11,105 11,772 12,303 11,592 12,881 E00-E89 Endocrine, nutritional and metabolic diseases 3,272 3,632 3,821 4,216 5,134 5,301 9,999 F01-F99 Mental, Behavioral and Neurodevelopmental disorders 2,798 2,669 2,969 3,186 3,534 3,254 4,259 G00-G99 Diseases of the nervous system 1,961 1,756 1,751 1,961 2,378 2,407 4,308 H00-H59 Diseases of the eye and adnexa 1,919 1,548 1,682 1,972 2,757 2,028 4,712 H60-H95 Diseases of the ear and mastoid process 861 884 827 984 1,207 1,000 2,034 I00-I99 Diseases of the circulatory system 18,002 17 ,701 17,960 19,348 23,015 24,683 49,100 J00-J99 Diseases of the respiratory system 1,517 1,613 1,472 1,587 2,026 1,444 2 472 K00-K95 Diseases of the digestive system 1,107 1,149 1,145 1,226 1,333 1,302 1,644 M00-M99 Diseases of the musculoskeletal system and connective tissue 6,166 5,873 5,566 5,905 6,817 5,531 14,796 N00-N99 Diseases of the genitourinary system 1,021 1,115 1,090 1,160 1,386 1,400 2,400 Q00-Q99 Congenital malformations, deformations, and chromosomal abnormalities 167 199 183 188 240 293 689 S00-T88 Injury, poisoning and certain other consequences of external causes 2,186 2,038 2,136 2,191 2,438 3,004 4,187 Other classes of illnesses (probably L, O, P, R, U, V, Z) 321 362 365 415 485 393 605 Source: NCPHA 169 Table A.16: Persons over 16 years of age having received expert decision for the first time by main groups of diseases and by severity (2019) Source: NCPHA Mild/No Very severe Severe Moderate (<50%) A00-B99 Certain infectious and parasitic 251 53 32 58 diseases C00-D49 Neoplasms 7,716 4,908 1,042 136 E00-E89 Endocrine, nutritional, and 140 657 1,737 738 metabolic diseases F01-F99 Mental, Behavioral and 836 914 906 142 Neurodevelopmental disorders G00-G99 Diseases of the nervous system 418 512 751 280 H00-H59 Diseases of the eye and adnexa 455 387 860 217 H60-H95 Diseases of the ear and mastoid 34 99 486 242 process I00-I99 Diseases of the circulatory system 2,759 4,676 6,948 3,619 J00-J99 Diseases of the respiratory system 58 128 641 690 K00-K95 Diseases of the digestive system 177 374 376 180 M00-M99 Diseases of the musculoskeletal 380 1,200 3,142 1,444 system and connective tissue N00-N99 Diseases of the genitourinary 334 125 401 161 system Q00-Q99 Congenital malformations, deformations, and chromosomal 14 23 87 43 abnormalities S00-T88 Injury, poisoning and certain other 384 232 955 615 consequences of external causes Other classes of illnesses (probably L, O, P, 48 59 123 91 R, U, V, Z) Table A.17: Children up to 16 years of age having received expert decision for the first time by main groups of diseases and severity (2019) Very severe Severe Moderate Mild/No (<50%) A00-B99 Certain infectious and parasitic 35 4 diseases C00-D49 Neoplasms 90 6 11 9 D50-D89 Diseases of the blood and 14 19 5 11 blood-forming organs + immune mechanism E00-E89 Endocrine, nutritional, and 22 195 10 11 metabolic diseases F01-F99 Mental, Behavioral and 87 257 284 152 Neurodevelopmental disorders G00-G99 Diseases of the nervous system 90 87 178 58 H00-H59 Diseases of the eye and adnexa 13 10 43 33 H60-H95 Diseases of the ear and mastoid 26 15 32 15 process I00-I99 Diseases of the circulatory system 4 4 7 9 170 J00-J99 Diseases of the respiratory 1 3 400 264 system K00-K95 Diseases of the digestive system 4 15 24 4 M00-M99 Diseases of the 3 48 49 10 musculoskeletal system and connective tissue N00-N99 Diseases of the genitourinary 3 20 9 3 system Q00-Q99 Congenital malformations, 126 91 301 97 deformations, and chromosomal abnormalities S00-T88 Injury, poisoning and certain 5 3 26 9 other consequences of external causes Other classes of illnesses (probably L, O, 3 7 60 7 P, R, U, V, Z) Table A.18: Persons having received expert decision for the first time (incl. below 50% severity) by age groups (2005-2019) Age groups (# People certified 1st 2005 2010 2015 2016 2017 2018 2019 time) Children (up to 16 y) 4,674 3,833 5,014 4,228 4,070 3,915 3,441 Working age young (16-29) 4,045 2,357 1,757 1,590 1,527 1,403 1,228 Working age mature (30-49) 17,460 12,146 11,632 10,687 10,340 10,128 8,908 Working age seniors (50-59) 30,483 18,780 17,942 15,504 14,845 14,573 13,250 (Pre)retirement (60+) 63,190 31,164 34,420 28,875 25,879 26,957 32,108 Table A.19: Persons having received 1-st time expert decision by age groups and severity (2019). Very severe Severe Moderate Low (<50%) Children (up to 15 years of age) 526 780 1,443 1,690 Working age young (16-29) 231 351 424 222 Working age middle (30-49) 1,585 2,355 3,261 1,707 Working age senior (50-59) 2,386 3,185 4,950 2,729 (Pre)retirement (60+) 9,802 8,456 9,852 3,998 Source: NCPHA Table A.20: Disability appeals and revoked decisions (2017 -2020) Status at 2017 2018 2019 6/2020 Number of appealed expert decisions of TMECs 9,779 10,626 13,275 4,648 Number of revoked expert decisions of TMEC 8,286 8,857 6,263 2,016 Number of appealed expert decisions of the NMEC 138 202 188 104 Number of revoked expert decisions of the NMEC 26 10 13 0 Source: Ministry of Health (MOH) Annual Reports 171 Table A.21: Checks on signals and complaints, and planned inspections (2015 -2020) 2019 2018 2017 2016 2015 Checks on signals and complaints 5,822 7,860 15,174 11,935 6,995 done by NMEC 4,449 3,467 3,013 done by RHI 173 4,393 12,161 no data available done by other entities (not specified) 1,200 - - Target 3,000 3,000 3,000 3000 3000 Inspections on the organization and quality of 1,891 1,649 1,712 1,324 1,884 the activity of TMEC, MAC & GP done by NMEC 104 118 111 0 0 done by RHI 1,787 1,531 1,601 1,324 1 884 Source: MH Annual Reports ADMINISTRATIVE DATA - DISABILITY BENEFITS Table A.22: Data on the number of applicants and approved applications for individual needs assessment by the type of benefit requested Individual assessment applicants No of applicants for the period No of approved applications by type of benefit requested 01.04.2019– 14.06.2020 01.04.2019 – 14.06.2020 Applicants for personal 35,275 33,976 assistance Applicants for benefits under the Persons with Disabilities Act 348,686 n/a (PDA) Source: SAA Table A.23: Disability pension recipients by type of pension (2012-2019) 2012 2013 2014 2015 2016 2017 2018 2019 Disability pension for 360,594 369,007 375,791 380,789 383,312 383,981 383,886 376,041 general illness - employees Disability pension for general illness - 1,065 919 806 699 596 507 434 368 cooperative farmers Disability pension for general illness – 1,046 976 916 851 805 738 697 647 self-employed craftsmen and merchants Disability pension for 76 72 68 64 61 60 56 48 general illness - 172 military/service men Military disability 2,628 2,515 2,419 2,303 2,232 2,134 2,026 1,918 pension Civil disability 177 169 162 155 151 138 135 132 pension Social pension for disability 47,307 47,720 47,893 48,548 49,793 50,428 50,948 50,451 (without work record) Occupational disease/work accident related 7,037 6 ,725 6,393 6,034 5,744 5,540 5,276 4,972 disability pension - employees Occupational disease/work accident disability 133 121 109 99 89 77 68 61 pension - cooperative farmers Occupational disease/work accident related disability 37 33 31 31 25 26 25 23 pension - craftsmen/merc hants Occupational disease/work accident disability 7 8 8 8 8 8 8 8 pension - military/service men Disability pensions (without 420,107 428,265 434,596 439,581 442,816 443,637 443,559 434,669 survivors’ pension) Disability pensions (incl. 503,093 509,359 511,340 513,453 518,109 518,067 517,743 509,091 survivors’) Source: National Social Security Institute (NSSI) 173 Table A.24: Annual expenditures for disability pensions by type of pension, in thousand BGN (2012-2019) 2012 2013 2014 2015 2016 2017 2018 2019 Pensions for general illness - 1,164 153 1,253 398 1,305,447 1,343,380 1,375,776 1,447,055 1,565,878 1,618,066 employees Pensions for general illness - 3,288 3,007 2,703 2,389 2,107 1,956 1,930 1,717 cooperative farmers Pensions for general illness - private 2,368 2,360 2,262 2,148 2,048 2,086 2,183 2,132 craftsmen and merchants Pensions for general illness - 329 325 312 295 287 274 258 250 military/service men Pensions - military 9,298 9,395 9,244 9,033 8,852 8,869 9,160 9,098 disability Pensions - civil 449 447 445 436 425 415 401 404 disability Pensions - social pension for 250,488 270,738 284,857 286,085 272,207 260,892 251,762 123,010 disability Occupational disease/work accident- 40,692 41,483 40,915 39,810 38,739 38,411 39,114 38,962 related pension - employees Occupational disease/work accident- 533 512 489 443 409 395 416 374 related pension - cooperative farmers Occupational disease/work accident- 141 133 126 122 120 125 141 153 related pension – craftsmen and merchants Occupational disease/work accident disability 75 82 79 78 77 77 81 86 pension - military/service men Total expenditures for disability 1,471,813 1,581,881 1 646,878 1,684,218 1,701,047 1,760,555 1,871,325 1,794,252 pensions (in thousands of BGN) Source: NSSI 174 Table A.25: Recipients of disability pension by severity of disability and gender (2019) Very Severe Moderate Total Men Women severe Disability pensions for general illness 68,426 143,527 165,151 377,104 167,994 209,110 Disability pensions for occupational 507 939 3,618 5,064 3,523 1,541 disease/work accident Social disability pensioners 20,865 29,586 n/a 50,451 29,020 21,431 Total 89,798 174,052 168,769 432,619 200,537 232,082 Source: NSSI Table A.26: People receiving disability pensions per severity of disability and employment (2019) Very severe Severe Moderate Total Working and receiving disability 7,227 32,635 60,944 100,806 pension for general illness Working and receiving disability pension for occupational 33 174 952 1,159 disease/work accident Working and receiving social 795 3,281 n/a 4,076 disability pension Total 8,055 36,090 61,896 106,041 Source: NSSI Table A.27: Poverty line and average pensions in Bulgaria in 2019 (per month) 2019 Poverty line 211,17 € Minimal amount for old age and work experience pension (length of service) 112,19 € Disability pension for general illness - for very severe disability 129,02 € Disability pension for general illness - for severe disability 117,80 € Disability pension for general illness - for moderate disability 95,37 € Disability pension for occupational/work related disability - for very severe 140,24 € disability Disability pension for occupational/work related disability - for severe disability 129,02 € Disability pension for occupational/work related disability - for moderate 112,19 € disability Social disability pension - for very severe disability 81,44 € Social disability pension - for severe disability 74,65 € 175 Table A. 28: Annual newly granted and terminated disability pensions (2010 -2019) 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Number of newly granted disability 56,030 56,379 54,007 52,137 52,472 55,921 55,867 51,659 50,950 45,473 pensions (Personal and survivors) Number of terminated disability pensions 51,585 50,829 49,150 46,012 50,479 53,806 51,210 51,460 51,278 54,125 (Personal and survivors) Source: NSSI Table A.29: Recipients of benefits who have undergone individual needs assessment in 2019 Benefits users by the type of benefit No of users of benefits for 2019 1. Monthly financial payments users 654,960 2. Personal vehicle purchase 6 3. Living space adaptation 28 4. Rehabilitation and balneotherapy services 4,982 5. Rent for public housing 1,035 Targeted support for assistive technology, devices, 6. 83,788 facilities, and medical equipment 7. Personal assistance 27,923 Source: SAA Table A.30: Persons with disability receiving disability related benefit (2017-2019) 2019 2018 2017 Total number of people with disabilities receiving monthly social 654,960 assistance Annual expenditure (accrued) for monthly social assistance paid to 441,699,542 BGN no data people with disabilities (BGN) Annual expenditure (paid) for monthly social assistance paid to 313,081,930 BGN people with disabilities (BGN) Source: Social Assistance Agency (SAA) 176 Table A.31: Tax relief benefits for disability (2017 -2019) Tax relief (Declaration 50, 2019 2018 2017 in BGN) Tax relief on income from personal labor (cost to the 279,250,512.00 BGN 281,966,242.89 BGN 269,247,558.84 BGN budget) Tax relief for parents of children with disabilities 17,354,158,50 BGN 6,639,714.62 BGN 6,502,181.04 BGN (cost to the budget) Total 296,604,670,50 BGN 288,605,957.51 BGN 275,749,739.88 BGN Number of people with disabilities, benefitting from 50,897 56,882 55,803 tax relief on income from personal labor (number) Number of people, benefitting from tax relief 3,091 3,216 3,180 for parents of children with disabilities (number) Source: National Revenue Agency (NRA) Table A.32: Persons with disabilities receiving additional monthly supplement for social integration (2010-2019) 2019 (new 2018 2017 2015 2010 law) Annual expenditure (in 403,016 151,568 131,574 138,466 123,033 thousand BGN) Total average monthly number of persons receiving monthly 636,093 497,486 500,016 524,504 477,776 supplement for transport services 496,503 499,932 230,782 419,614 for information and 70,484 74,514 41,960 103,325 telecommunication services for training 3,169 97 n/a 423 for municipal housing rent 959 974 933 for spa treatment & no data 5,899 5,733 525 9,568 rehabilitation for nutrition and medications 418,683 403,535 204,557 358,523 for accessible information 107,063 109,564 41,960 70,274 for home adaptation 7 0 3 15 for the purchase and 5 3 8 2 adjustment of vehicles vignette sticker provided 237,392 229,037 218,835 186,125 Source: SAA 177 Table A.33: Number of persons with disabilities receiving targeted benefits (av erage number per month) for 2019 Persons with disabilities receiving targeted benefits (average per month 2019 Targeted assistance for purchase and adjustment of personal vehicles 6 Targeted housing reconstruction assistance 28 Targeted assistance for manufacturing, purchase and repair of medical devices 6,994 Spa treatment and rehabilitation services 3,820 Municipal housing rent 1,035 Total 8,485 Annual expenditure (in BGN) 32,527,918 Source: SAA Table A.34: Beneficiaries of assistance by others 2019 2019 Allowance for personal assistance (since 2019 - based on PDA INA: >90% disability) 9,029 Expenditure for personal assistance in BGN (since 2019) 18,914,396 Home care services (personal assistant, home assistant or social assistant) 23,272 Expenditure for home care services (in BGN) 75,727,970 Source: SAA Table A. 35: Targeted benefits for raising children with disabilities (2010 -2019) 2019 2018 2017 2015 2010 Monthly allowance for a child with permanent 25,717 26,395 26,393 25,599 20,126 disabilities (average number of recipients per month) Average monthly expenditure, in 169,023,894 170,816,806 161,500,024 86,969,240 46,444,409 thousand BGN) Source: SAA 178 EUSILC DATA Table A.36: Self-perceived long-standing limitations in usual activities due to health problem in 2010 and 2019 (population older than 16) 2019 2010 Bulgaria EU-27 Bulgaria EU-28 Severe 3.20% 7,50% 3.80% 8.10% Some 13.00% 17.20% 11.70% 17.00% None 83.90% 75.3% 84.50% 74.90% Source: EUSILC Table A.37: Share of population over 16 years of age at risk of poverty or social exclusion (2010 and 2019) 2019 2010 Bulgaria EU-28 Bulgaria EU-28 With some or severe limitations 51% 29% 67% 30% With no limitations 29% 18% 46% 21% In-work at-risk-of-poverty rate with some or severe limitations 7% 11% 9% 10% In-work at-risk-of-poverty rate with no limitations 9% 9% 8% 8% At risk of severe material deprivation with some or severe limitations 33% 9% 63% 11% At risk of severe material deprivation with no limitations 18% 4% 43% 7% Source: EUSILC 179 Annex 2: Legal Framework 1. LAWS Constitution of the Republic of Bulgaria295 According to Article 6 (1) of the Constitution of the Republic of Bulgaria “All human beings are born free and equal in dignity and rights”. The equality of all citizens before the law is ensured in paragraph 2: “All citizens296 are equal before the law. No privileges or restriction of rights are allowed on the grounds of race, national or social origin, ethnic self-identity, sex, religion, education, opinion, political affiliation, personal or social status or property status.” Particular attention in the Constitution is paid to the right to work, social security and social assistance to persons with physical or mental disabilities. The State is obliged to create conditions for them to exercise their rights. The Constitution stipulates that old people who have no relatives and cannot support themselves from their property, as well as the persons with physical and mental disabilities, have the right to special protection of the state and the society. The constitutional provisions correspond to the UNCRPD requirements to protect and respect human honor and dignity, and to prevent any discrimination. Persons with Disabilities Act The main legal document regulating disability matters in Bulgaria is the Persons with Disabilities Act.297 It was adopted in 2018 and entered into force on January 1, 2019. The Law’s main objective (Article 2) is to promote, protect and guarantee full and equal rights and freedoms of people with disabilities; to create conditions for social inclusion of people with disabilities and to contribute to respect for the inherent human dignity of people with disabilities; and to provide support for people with disabilities and their families. Some key definitions from the Law are provided below: People with disabilities are persons with physical, mental, intellectual, and sensory disability, which in interaction with the surrounding environment could hinder these persons’ full and effective participation in public life (§ 1.1). Persons with permanent disabilities are persons with permanent physical, mental, intellectual, and sensory deficits that in interaction with the surrounding environment could hinder their full and effective participation in public life, and for whom a medical report issued by a relevant authority has established the type and degree of disability of 50 or more percent. Individual need is an individualized need for support, which complements the capabilities of a person and/or provides guidance for specific support activities according to the reported problem areas. Persons with difficulties moving are persons who have a permanently deficit pertaining to standing, mobility and endurance. 295 The Constitution, Article 6 (1) https://lex.bg/laws/ldoc/521957377 296 The term "citizens" refers to all individuals to whom the Constitution applies. 297 The Persons with Disabilities Act https://www.lex.bg/bg/laws/ldoc/2137189213 180 Rehabilitation is a continuous recovery process that helps a person with a disability to reach an optimal physical, intellectual, mental, and social level of activity, providing him/her with opportunities to change his/her life to a higher degree of independence. Prevention is actions taken to prevent: (i) physical, intellectual, mental, or sensory impairments; (ii) deterioration in impairments or secondary impairments due to prolonged dysfunction or primary impairment; and to provide (iii) adaptation of the environment. The Act introduces an individual approach in providing support to persons with disabilities and an individual assessment of their needs (Chapter III, Individual Needs’ Assessment). The assessment should examine functional difficulties that a person with a disability experiences related to his/her health condition and the presence of barriers/ facilitators to the performance of daily and other activities, and should identify the type of support the person needs to optimize her or his functioning. The individual needs assessment combines information about a person with a disability and difficulties in functioning she or he experiences in carrying out life activities in her/his environment to recommend person specific support measures. As per Article 21, Paragraph 1, the comprehensive individual needs’ assessment should be performed by a specialized department within the Social Assistance Directorates (territorial branches of the Social Assistance Agency). The assessment methodology should be proposed by MLSP and adopted by the Council of Ministers. Article 5, Paragraph 1 identifies the following areas of support for persons with disabilities: healthcare, education, employment, housing, accessible urban environment and public buildings, transport, culture, sports, personal life, public and political life, justice; etc. Paragraph 2 lists interventions, including: medical, professional, social, labor, and psychological rehabilitation, education and vocational training, services supporting access to employment, accessibility and reasonable accommodation, social services, financial support, accessible information, access to justice and legal protection, ensuring personal mobility with a maximum degree of independence, personal assistance, universal design, etc. The Act guarantees access to employment of persons with permanent disabilities in a regular working environment. Article 38 paragraph 1 stipulates quotas for employment of persons with permanent disabilities. The quotas depend on the staff number. Employers with 50 to 99 workers must hire one person with a disability, while employers with 100 and over 100 workers 2.0 percent of employees. The Law also defines a limited number of quota exceptions: specific factors that prevent employment of people with disabilities, lack of people with disabilities in the local labor market, and application of alternative employment measures for people with disabilities. Entrepreneurs who create production units or production groups of people with disabilities may use the rights defined for specialized enterprises and cooperatives of people with disabilities. The Agency for People with Disabilities supports financially such enterprises through different projects and programs, including through reimbursing 50 per cent of the social insurance contributions due, compulsory health insurance and additional compulsory pension insurance of the employed persons with disabilities. The Act also regulates access to media. According to Article 6, the Bulgarian National Television, the Bulgarian National Radio, and the Bulgarian Telegraph Agency must provide information accessible to people with disabilities and must include information on people with disabilities in their programs. The Act stipulates the right to independent decision-making. Persons experiencing serious difficulties to independently exercise his/her rights in performing specific legal actions, have the right to a supported decision-making. The supported decision-making is defined as a combination of social interventions, which aim to support a decision-making process leading to legal consequences and concrete results for a person with disability. This support refers to cases when a person with a 181 disability has problems to understand information on which the decision for performing a specific legal action is based; to assess the nature and consequences of possible decisions for the concrete legal action; to make a connection between the information and the assessment itself. The Act also requires that all structures of the judiciary and state institutions ensure an effective access to justice to people with disabilities on an equal base with all people. The Act describes financial support for persons with disabilities depending on their needs determined by the individual assessment. This support is intended to compensate the costs related to overcoming difficulties caused by the type and severity of disability (Based Article 66). According to Article 69, financial support for people with disabilities consists of: a monthly financial support according to the degree of disability and targeted benefits according to the type of disability. Entitled to financial support are persons over 18 years of age with permanent disabilities. Depending on the degree of disability, the support is as follows: • from 50 to 70.99 percent degree of disability: 7 percent of the poverty line, • from 71 to 90 percent degree of disability: 15 percent of the poverty line, • over 90 percent degree of disability: 25 percent of the poverty line, • over 90 percent degree of disability, with assistance by others and receiving a disability pension: 30 percent of the poverty line, • over 90 percent degree of disability, with assistance by others and receiving a social pension for disability: 57 percent of the poverty line. Targeted assistance is for: (i) provision of technical aids, according to approved quality standards; (ii) purchase of a personal motor vehicle; (iii) dwelling adaptation; (iv) balneal-therapy and/or rehabilitation services; (v) rent for a municipal residence. The Act elaborates further on requirements to access these benefits. The Act (Chapter VII) tasks the Agency for People with Disabilities to establish, coordinate and maintain public, electronic Information System for People with Disabilities containing data on their health condition, educational degree and qualification, personal opportunities for social inclusion, professional realization, socio-economic status, demographic, and other data. These data should enable monitoring and analysis of the socio-economic status of people with disabilities for planning activities related to meeting their individual needs and for developing sector specific policies. It also requires that APD establishes a Register of all specialized enterprises and cooperatives of people with disabilities. The register should support monitoring and control of these entities, including their activities performed during the implementation of targeted projects and programs financed under this Act. The State Drug Agency is tasked to establish a Register of entities repairing technical aids (devices, equipment, medical devices, etc.) for people with disabilities. The Act also stipulates the transformation of the Agency for People with Disabilities into a State Agency for People with Disabilities. Rules for the Implementation of the Persons with Disabilities Act The Rules298 regulate procedures and ways in which the Act is to be applied. They instruct that an electronic file of a person with a disability must be created in an integrated information system after a person with disability makes a request for an individual needs assessment and support under the 298 The Rules for the Implementation of the Persons with Disabilities Act. https://www.lex.bg/bg/laws/ldoc/2137192229 182 Persons with Disabilities Act (Article 14, Paragraph 2). Further, it regulates the terms of validity of the individual needs’ assessment (Chapter III, Article 18). The Rules determine the procedures and ways to access support for social inclusion in the following areas: • Social rehabilitation (Chapter IV, Section 1): APD develops programs and finances projects for rehabilitation and integration of people with disabilities, the Executive Director of APD approves a methodology for financing of such projects. • Employment (Chapter IV, Section 2): Annually, employers should report to the respective territorial division of the Employment Agency on actions taken to employ persons with disabilities related to the quota system. The territorial divisions of the Employment Agency and the territorial directorates of the General Labor Inspectorate exchange ex officio this information. The General Labor Inspectorate carries out a specialized control. APD provides annual information about the financial possibilities for projects and programs for promotion of business initiatives in the interest of people with disabilities. The Minister of Labor and Social Policy approves a National Program for Employment of People with Disabilities. The Program objective is to create conditions for employment of people with permanent disabilities, increase their employability and encourage and support employers to hire them. • Accessible environment and reasonable accommodation, accessible information, and personal mobility (Chapter IV, Section 3): The National Program for Accessible Housing Environment and Personal Mobility has two main components: Affordable living environment and Personal mobility. APD develops programs and finances projects for construction of accessible architectural environment for people with disabilities at cultural, historical, sports and other sites. • Financial support (Chapter IV, Section 4): The Social Assistance Directorate issues an order for granting financial support to a person with completed individual needs assessment according to the conclusions of the assessment. The order should be communicated in writing to the person who has submitted the application for support. • Information System (Chapter IV, Section 5): A profile of each person with a disability is maintained in the information system for people with disabilities housed by APD. The state and local bodies that have responsibilities regarding the rights of people with disabilities collect, maintain, and provide data to the information system for people with disabilities. The exchange of information should be carried out in compliance with the requirements of the EU and Bulgarian legislation related to the protection of personal data. Anti-Discrimination Act The Anti-Discrimination Act299 builds upon the constitutional principles of non-discrimination and equality before the law as per Article 6 of the Constitution300 of the Republic of Bulgaria. It introduces mechanisms for enforcement of the prohibition of discrimination. Article 2 describes the purpose of the Law, which is to provide every person with the right to equality before the law, equality in treatment and in opportunities for participation in public life, and effective protection against discrimination. 299 The Anti-Discrimination Act. https://www.lex.bg/laws/ldoc/2135472223 300 Article 2. https://lex.bg/laws/ldoc/521957377 183 Article 4 establishes that any direct or indirect discrimination - based on sex, race, nationality, ethnicity, human genome, citizenship, origin, religion or faith, education, beliefs, political affiliation, personal or social status, disability, age, sexual orientation, marital status, property status, as well as on any other grounds described by law or in an international treaty to which Bulgaria is a party – is prohibited. The Act underlines that a harassment on the grounds mentioned above, sexual harassment, provocation to discrimination, persecution, and racial segregation, as well as the construction and maintenance of an architectural environment that hinders access of persons with disabilities to public places are considered as discrimination. The Act stipulates protection against discrimination related to the right to work, education and training, and other rights such as participation in trade unions, professional organizations, and employers' organizations, etc. The Act describes further the process for protection against discrimination and provides for the establishment of the Commission for Protection against Discrimination. Social Services Act The Social Services Act301 is newly adopted, after a long period of discussions and clarifications to answer expectations of all members of the Bulgarian society. The Act changed the legal framework for planning, delivery, financing, and control of social services. The approach underlying this Act is to ensure harmonization with other laws, create a coherent link between this Act, the Persons with Disabilities Act and the Personal Assistance Act, develop more friendly procedures, etc. Article 1 regulates provision, use, planning, financing, quality, control, and monitoring of social services in Bulgaria. The Act guarantees equal access to social services, meeting individual needs of beneficiaries, the right of every person to support for living in a home environment and in the community, promoting an integrated approach in providing support to individuals and promotion and development of the public-private partnership in the provision of social services. The exercise of human rights and prohibition of discrimination are ensured in Article 8: the provision of social services should not discriminate directly or indirectly persons based on their sex, race, ethnic origin, human genome, nationality, origin, religion or faith, education, political affiliation, personal or social status, disability, age, sexual orientation, marital status, property status or any other characteristic established by law or in an international agreement to which Bulgaria is a party. Based on the age of users, social services may be for children and for adults. Based on specific needs of users, social services may be for: all children, children at risk as defined by the Child Protection Act, parents, adoptive parents, persons caring for children, candidates for adoptive parents and candidates for foster families, children and adults with disabilities, adults in a crisis situation or with a need to overcome consequences of such a situation; older adults (over working age); persons who take care of adults. Social services can be used without a formal referral: every person has the right to use publicly available social services without a referral from the Social Assistance Directorate or relevant municipality and without a preliminary assessment of needs. The Social Services Act gives opportunities to obtain a referral, if one is needed for access to specialized services during the provision of a publicly available social services. In cases where urgent support is necessary to a person 301 The Social Services Act. https://www.lex.bg/bg/laws/ldoc/2137191914 184 in a crisis, a victim of domestic violence or to a victim of trafficking, social services are provided without a referral and the service provider notifies immediately the Social Assistance Directorate for undertaking actions provided by the law. The Act underlines the rights of people with disabilities to social services as regulated by the Persons with Disabilities Act; to use these services without a preliminary assessment of the needs and a referral from the Social Assistance Directorate/relevant municipality. The Act defines conditions for placing children into residential care. The placement is subject to mandatory judicial control except for residential placement for up to 30 days of children with permanent disabilities in need of constant medical supervision and medical care, and when there are no grounds for accommodating the child outside his/her family (Article 25 of the Child Protection Act302). Residential care for children up to three years of age is not allowed except for the provision of residential care to children with permanent disabilities who need constant medical supervision and medical care, which cannot be provided in another way. For children up to 18 years of age, the maximum allowed period of residential care - as a measure for protection of the child – cannot be longer than two years and the placement is subject to an obligatory review every 6 months. This rule does not apply to cases of children who do not have the opportunity to be reintegrated into the biological family, adopted, and placed with relatives or in a foster family. The Act provides that parents of children with permanent disabilities, families that are subject of care under Article 26 of the Child Protection Act, families and persons taking care at home of adults and elderly people with permanent disabilities and incapacity for self-care have the right to a substitute care, under conditions and in accordance with procedures specified by the Act. Article 93 of the Act defines services of an assistant as a specialized social service that includes support by an assistant for self-service, mobility and travelling, changing and holding a body position, performance of daily and household activities, and communication. The assistant support can be provided to persons above working age who are not able to self-service themselves, children and adults with permanent disabilities in need of support of an assistant, etc. The Act espouses holistic, integrated approach to service provision. It provides (Article 145) that integrated health and social services should be provided to children and persons with permanent disabilities, persons with chronic diseases, older adults unable to self-service themselves. The integrated approach is of particular importance for people with disabilities because they often need complex actions, services and support measures. This approach includes coordination and interaction with other government bodies, as well as coordination and interaction within the system of social services. Preventing the abandonment of a child with a disability is regulated by Article 36b of the Act. When a child with a disability is born and after disability has been established, parents must be informed immediately and in an appropriate manner by the hospital. The medical staff of the hospital where a child with a disability is born is obliged to make efforts to motivate the parents not to abandon their child, as well as to provide them with full information about the condition of the child, possible treatments, the child’s future development and the necessary care. The hospital should inform immediately the Social Assistance Directorate and the provider of social services for early intervention and support to the parents and the child with disabilities. The Act introduces new quality standards and methods for their verification. Only quality services will be developed and funded. Standards for quality of social services (Article 105) pertain to the service delivery organization and management, staff qualifications and professional development, service 302 The Child Protection Act. https://www.lex.bg/laws/ldoc/2134925825 185 effectiveness in view of the achieved results for the beneficiaries in response to their needs, etc. All social services should be provided in accordance with the Ordinance for the Quality of Social Services (Article 109). The Ordinance will determine quality standards, criteria for meeting them, principles for the elaboration of programs to develop quality standards by the social services’ providers, methods for monitoring quality of social services, procedures to control, monitor and evaluate quality and efficiency of social services. The Act stipulates that all private providers of social services will have to be licensed. Municipal services will have to meet the same high-quality standards, or loose additional funding (Article 31). The Act pays particular attention to social service providers and their licensing. A social service provider is defined as a person or entity responsible for the provision of social services. Municipalities can provide all social services and are responsible for the provision of social services financed from the state and municipal budgets. Municipalities provide social services through legal entities especially created by a municipality to deliver social services and by contracting out the provision to private providers of social services. Private providers of social services are Bulgarian natural persons registered under the Commercial Law or legal entities; or natural persons carrying out commercial activities or legal entities registered in the European Union or in another state - party to the Agreement on the European Economic Area. All social service providers may provide social services in Bulgaria only after they have received a license from the Executive Director of the Agency for the Quality of Social Services. Some key terms defined by the Act: • Social exclusion is a condition in which a person, due to personal or objective reasons, does not have conditions and opportunities for full participation in various areas of public life. • Support in the home environment is the provision of personal care at home to children and persons with permanent disabilities and persons incapable of self-care to meet their daily needs for self-care, movement, communication, household activities, organization of everyday life and participation in public life. • Rehabilitation aims to improve physical strength and functional health of persons with disabilities and persons with problems in the musculoskeletal system and joints, as well as recovery and development of sensory skills of persons with disabilities, outside the scope of medical rehabilitation. • Skills training is an activity carried out in a specialized environment to prepare children and adults for independence, independent living, independent coping with problems and difficulties, as well as to acquire skills needed for care and support to children and dependent family members. • Acquisition of labor skills is an activity to help persons with permanent disabilities acquire skills for participation in labor activities. • Day care provides care in a specialized environment to individuals (adults) and in groups for children with permanent disabilities, at least 4 hours a day, through which their daily needs are met. • Residential care provides 24/7 accommodation and care for children, young people up to 25 years of age, persons with permanent disabilities and persons above working age incapable of taking care of themselves. • Substitute care is a short-term care service provided to parents of children with permanent disabilities, relatives or friends, foster families, families and persons who provide home care for adults with permanent disabilities and incapacity for self-care and for elderly people unable to self-care in the event that care providers are unable to provide the care, or to prevent separation by providing a short-term respite to the care provider. 186 • Specialized support to understand information and choose a service is provided to enable a beneficiary to understand information, express his or her wishes and make an informed choice. • Assistant is a paid person who provides hourly care in a home environment to persons with permanent disabilities or persons above working age incapable of self-care in order to support self-care, movement and mobility, changing and maintaining a body position, perform daily and household activities and communication. • Early intervention for children with disabilities is specialized support for children with disabilities and children at risk of developmental delay up to 7 years of age and their families that includes early identification of risks to children's health and development, implementation of early intervention measures to improve the children’s health state and development and to build skills for their upbringing. • Children with permanent disabilities are children with at least 50 percent disability. • Adults with permanent disabilities are adults with at least 50 percent of disability or permanently reduced work capacity. • Persons who take care of adults are family of household members who take care of a person with permanent disability or a person of working age incapable of self-care, for which they do not receive remuneration or other form of financial support. The Social Services Act introduces bodies at the state and local levels - councils, agencies, and other administrative entities, to establish a mechanism for cooperation and for monitoring the system of social services. Child Protection Act The Child Protection Act303 regulates child protection, including provision of special care for children with disabilities. For the purposes of the Act, the child protection is defined as a system of legislative, administrative, and other measures for guaranteeing the rights of every child. According to Article 4 Paragraph 12, a special care for children with disabilities should be provided to protect children’s rights. The Act stipulates that every child has the right to protection for his normal physical, mental, moral, and social development and to protection of his rights and interests. No restrictions of the rights or privileges of children based on race, nationality, ethnic affiliation, gender, origin, property status, religion, education and beliefs or disability are allowed. The Act regulates that child protection is implemented by the following authorities: the Chairman of the State Agency for Child Protection and the Agency administration, the Social Assistance Directorate, the Minister of Labor and Social Policy, the Minister of the Interior, the Minister of Education and Science, the Minister of Justice, the Minister of Foreign Affairs, the Minister of Culture, the Minister of Health, and mayors of municipalities. The Social Assistance Directorate provides special care for children with disabilities through multilevel actions, including consultations with a medical doctor, psychologist, pedagogue, or other specialists, if necessary, depending on the type and severity of disability. 303 The Child Protection Act. https://www.lex.bg/laws/ldoc/2134925825 187 Health Act According to the Constitution of the Republic of Bulgaria, all citizens are entitled to health insurance guaranteeing to them affordable medical care and free medical services under terms and conditions determined by law.304 Protection of public health as a “state of complete physical, mental and social well-being” is defined as a national priority under the Health Act.305 The Act guarantees equality in using health services, provision of quality and affordable healthcare, health promotion and integrated disease prevention, and prevention and reduction of risk to public health from the adverse impact of factors in the living environment. Through the provisions in the Act, the state provides special health protection for people with physical disabilities and mental disorders. The Act (Article 80) stipulates that the quality of medical care should be based on medical standards in specialties approved under Article 6, Paragraph 1 of the Law on Medical Establishments306 and the rules for good medical practice, adopted and approved under Article 5, Item 4 of the Law on Professional Organizations of Medical Doctors and Dentists.307 With regard to medical rehabilitation of people with disabilities, the healthcare standard is guaranteed through mandatory application of clinical pathways. People with disabilities have the right to health care as health insured persons, regardless of the type and degree of their disability. They can be treated in hospitals, which are contractual partners of the National Health Insurance Fund, in all clinical pathways, clinical procedures, highly specialized medical treatment, be provided medical devices when needed, according to the same principles on which the hospital treatment of other patients is based. The Health Act regulates disability assessment in Bulgaria (Article 101). It stipulates that medical diagnosis is essential for medical expertise. Medical expertise is performed for establishing: (i) temporary incapacity for work, (ii) type and degree of disability in children up to 16 years of age and in adults who have acquired the right to a social insurance old age pension under Article 68 of the Social Insurance Code, (iii) a degree of permanently reduced work capacity for persons in working age; (iv) an occupational disease. The Act defines permanently reduced work capacity as a condition in which due to chronic illness and injury a person has limited work capacity in connection with a permanent functional deficit of the respective impaired organ or system. The type and degree of disability is defined as a condition of chronic illness and injury in which the person experience permanent functional deficit of a relevant impaired organ or system. The medical expertise is organized and managed by the Ministry of Health and by the Regional Health Inspection. The type and degree of disability and the degree of permanently reduced work capacity is determined in percentages. The Act provides that principles and criteria for the medical expertise to establish disability (i.e. disability assessment), procedures to establish temporary incapacity for work, a type and degree of disability, a degree of permanently reduced work capacity, confirmation of an occupational disease, 304 Constitution, Article 52 (1). https://lex.bg/laws/ldoc/521957377 305 The Health Act. https://www.lex.bg/laws/ldoc%20/2135489147 306 The Law on Medical Establishments. https://www.lex.bg/laws/ldoc/2134670848 307 The Law on Professional Organizations of Medical Doctors and Dentists. https://www.lex.bg/laws/ldoc/2134419457 188 as well as conditions and administrative procedure to conduct medical expertise should be determined by an ordinance308 of the Council of Ministers. The Act established Territorial Medical Expertise Commissions (TMEC) and a National Medical Expertise Commission (NMEC) to carry out medical expertise. NEMC coordinates the development and implementation of policies pertaining to medical expertise. TEMC perform the expertise of the type and degree of disability, the degree of permanently reduced work capacity and occupational diseases, etc. The NEMC is responsible for the development of an information data base of all persons who have passed through TEMC/NEMC. The database should contain (for each person): an application- declaration for disability/ reduced work capacity certification/re-certification; a referral to medical expertise (medical protocol / medical direction) ); experts’ decision; a diagnosis of the primary disease; diagnoses of the co-morbidities; all performed medical-diagnostic activities related to the assessment; examinations performed by a doctor, related to the assessment; other data of importance for the assessment of permanently reduced work capacity type and degree of disability. Personal Assistance Act The Personal Assistance Act309 regulates the terms and conditions for the provision and use of personal assistance by people with disabilities. The law aims to help people with disabilities exercise their rights, have choices, live independently, be actively involved in society and have access to services and activities by providing personal assistance. The Act (Article 3) defines personal assistance as a mechanism to support people with disabilities to exercise their rights, participate fully in society, carry out activities that meet their personal, social and domestic individual needs, and to overcome barriers to their functioning limitations. The provision of personal assistance under this Act is based on the principles set out in the Persons with Disabilities Act: efficiency and effectiveness of assistance and respect for personal space, dignity, independence and autonomy of people with disabilities. The Act defines a user of personal assistance as a person with disability that has led to limitations in her ability for self-service in everyday life and to dependence on support from other people that compensates her functioning deficit and provides support for her to exercise her rights and fully participate in society. When a user of personal assistance is an underage person or a person with full incapacity, he/she must be represented by a legal representative and the consent of his/her legal representative must be sought. A beneficiary or a person authorized by her/him or her/ his legal representative choose an assistant, participate in negotiations on the conditions of employment, participate in the management and control of the type and duration of the work performed, sign the monthly report of the assistant for the hours worked by her/him, notify in writing the provider of personal assistance of a conflict with the assistant. The Act for Personal Assistance defines the users and beneficiaries of personal assistance as follows: (i) a child with disabilities who receives monthly allowances under Article 8e of the Family Benefits for Children Act; (ii) a person who receives a supplement for assistance by other people under Article 103 of the Social Security Code; (iii) a user of social services in the community, with the exception of community residential care or care in specialized institutions; (iv) a foreigner with a disability who has a long-term or permanent residence permit in the Republic of Bulgaria; (v) a foreigner with a disability who has been granted an asylum, a refugee or a humanitarian status; (vi) a foreigner with a disability 308 The Ordinance for the Medical Expertise. https://www.lex.bg/en/laws/ldoc/2137150573 309 The Personal Assistance Act. https://www.lex.bg/bg/laws/ldoc/2137189250 189 benefiting from temporary protection; (vii) a person for whom this service is provided in an international agreement to which Bulgaria is a party, provided that the degree of permanently reduced work capacity or the type and degree of disability are determined by the legislation in force in Bulgaria. Personal assistance is based on the state-guaranteed financial support, individual needs and choices of people with disabilities. To access it, an applicant has to undergo an individual needs assessment (see above). The Act stipulates (Article 18) that the provider of personal assistance is a municipality at the present address of a user. The mayor of the municipality can contract out the service provision a to Bulgarian natural person or legal entity, or to foreign natural person/legal entity that meet the Act’s requirements. An assistant is a natural person chosen by the user of personal assistance, a person authorized by her/him or her/his legal representative to provide personal assistance according to the individual needs assessment and the agreement under Article 14 paragraph 3 of the Act. Medical Establishments Act The Medical Establishments Act310 defines medical establishments as: • Organizationally separate structures on a functional principle, in which medical doctors or dentists independently or with the help of other medical and non-medical specialists perform all or some of the following activities: a) diagnosis, treatment and rehabilitation of patients; (b) monitoring pregnant women and providing maternity care; c) monitoring of chronically ill persons; d) disease prevention and early detection of diseases; (e) measures to promote and protect health; f) transplantation of organs, tissues and cells; and • Organizationally separate structures in which medical assistants, nurses, midwives or rehabilitators independently perform all or some of the following activities: (a) provision of medical and health care; b) carrying out manipulations; c) health promotion and disease prevention. Medical establishments can carry out training of students and postgraduate training of medical specialists, as well as scientific activity. They can provide social services and integrated health and social services under the terms and conditions of the Social Services Act. The Act describes (Article 27a) a medical establishment that can be specifically designed and established for children with disabilities – a center for complex treatment of children with disabilities and chronic diseases that carries out activities to support families of children with disabilities and chronic diseases in early detection, diagnosis, treatment and medical and psycho-social rehabilitation; long-term treatment and rehabilitation of children with disabilities and serious chronic diseases and training of their parents to take care in a family environment; visits by medical professionals to provide special care for children with disabilities and serious chronic diseases who live in a family environment and social service residential care; provision of specialist palliative care for children. These hospitals are set up by the Council of Ministers upon a proposal from the Minister of Health. The centers for complex treatment of children with disabilities and chronic diseases may provide social services under the Social Services Act. 310 The Medical Establishments Act. https://www.lex.bg/laws/ldoc/2134670848 190 Health Insurance Act The Health Insurance Act311 guarantees equality in the use of medical care to insured persons, including people with disabilities. Pursuant to Article 4 of the Act, mandatory health insurance should guarantee free-of-charge access of insured persons to medical care within a certain type, scope and amount of health activities and free choice of a healthcare provider that has a contract with a Regional Health Insurance Fund. The choice is guaranteed across the country and cannot be restricted for geographic and/or administrative reasons. Under the provisions of the Act, the state budget covers insurance for veterans and war victims who do not have other health insurance, persons with disabilities, victims of natural disasters and accidents. The state budget also covers insurance - unless covered otherwise – for persons who receive a disability pension, as well as parents, adoptive parents, spouses or one of the parents of a mother/ father who takes care of a child or a person with severe disability (90 percent and over) in need of assistance for daily routine. Insured persons suffering from chronic diseases who need continuous medical supervision, supportive care or some specific type of care are exempt from fees for a visit to their general practitioner, a dentist or for hospital admission. The list of diseases is an integral part of the National Framework Agreement between the National Health Insurance Fund (NHIF) and the Bulgarian Medical Association, the Bulgarian Dentists' Association and the Bulgarian Pharmacists' Union that regulates the type and scope of medical services paid by the NHIF. All war invalids and persons with over 71 percent disability are also exempt from the user fees for the NHIF-reimbursed health services. The Ministry of Health funds state-owned and municipal medical establishments for hospital care and state-run and municipal centers for mental health for medical services that by law or regulation fall within the state budget. Activities funded by the Ministry of Health include: (i) recreation (once a year), prevention and rehabilitation (twice a year) for veterans and war victims; (ii) in-patient treatment, day-care at a mental health institution, and rehabilitation through occupational therapy for persons with mental illness; (iii) diagnosis, treatment and specialized care for children at high medical risk outside the scope of compulsory health insurance; (iv) treatment of patients with active tuberculosis and medical check-ups from a disability assessment team. The National Health Insurance Fund pays for the following types of medical care: medical activities, medicinal products, dietetic foods for special medical purposes, medical devices, and highly specialized technical aids for individual use, as well as medical and technical aids and devices and facilities for people with disabilities, outside the scope of the compulsory health insurance. The Ministry of Health transfers funds to NHIF for these types of care, according to the budget law of NHIF for the respective year. The Act provides that all health insured persons have the right to safe and high-quality cross-border healthcare, regardless of the manner of its organization, provision, and financing. NHIF Fund is appointed as a national contact point for the cross-border healthcare and liaises with the respective EU members’ National Contact Points and with the European Commission. 311 The Health Insurance Act. https://www.lex.bg/laws/ldoc/2134412800 191 Social Security Code The Social Security Code312 guaranties rights to mandatory social insurance benefits (old-age, disability and survivors’ pension and other benefits). The scheme is administered by the National Social Security Institute (NSSI). Regarding disability benefits, the insurance provides compensation (sick leave) in case of temporary disability and vocational rehabilitation and pension in case of permanent disability. Persons receiving personal disability pensions are also entitled to cash benefits for prevention and rehabilitation, if they are below the age set out in Article 68(1) of the Code. The Code stipulates that an insured person is entitled to a disability pension when she/he has lost all or part of ability to work permanently or for a long time and she/he is assessed as having at least 50 percent of disability/ reduced work capacity. Labor Code The Labor Code313 provides different forms of support to persons with disabilities to facilitate their labor market inclusion, including employment quota for employees with disabilities, a percentage of jobs for vocational rehabilitation, a simplified regime of working hours, ban on night shifts and overtime, reduced working hours, protection against dismissal, compensation for occupational rehabilitation, etc. The labor rights and obligations should be exercised in good faith. Direct or indirect discrimination based on nationality, origin, sex, sexual orientation, race, skin color, age, political and religious beliefs is not allowed in exercising the labor rights and obligations. The Code (Article 140) prohibits night and overtime work for mothers with children up to 6 years of age, as well as mothers who take care of children with disabilities regardless of their age, except with their written consent. Employers are obliged to allow the use of paid annual leave or of unpaid leave in cases of declared emergency situation or declared extraordinary epidemic situation at the request of a mother or adoptive mother of a child of up to 12 years of age or of a child with a disability regardless of his/her age; an employee who is a single father or an adoptive parent of a child of up to 12 years of age or of a child with a disability, regardless of his/her age; an employee with permanently reduced work capacity of at least 50 percent. Special protection of persons with reduced work capacity is provided by the amendments to the Labor Code. An employee who, due to illness or an accident at work, is unable to perform work assigned to him, but without a danger to his health may perform other appropriate work or the same work with accommodation; may be employed in another job or in the same job under appropriate conditions as directed by the health authorities. According to the Code, workers, and employees with permanently reduced work capacity of at least 50 percent are entitled to basic paid annual leave of not less than 26 working days. An employee with permanently reduced work capacity below 50 percent, who is employed for a certain period and receives a lower salary than in the previous job, is entitled to a monetary compensation for the difference in wages. 312 The Social Security Code. https://www.lex.bg/laws/ldoc/1597824512 313 The Labor Code. https://www.lex.bg/laws/ldoc/1594373121 192 Civil Service Act The Civil Service Act314 provides for various forms of protection of people with disabilities in public administration. Discrimination, privileges, or restrictions based on race, nationality, ethnicity, sex, origin, religion, faith, membership in political, trade union and other public organizations or movements are not allowed in the public administration. The Act obliges the appointing authority to reserve for people with permanent disabilities at least: (ii) two per cent of the total number of staff positions in administration with staff over 50 people; (ii) one staff position in offices with 26 to 50 staff; (iii) one percent of the total number of positions for civil servants (under Article 142 paragraph 1, item 2 of the Law on the Ministry of Interior; Article 43, paragraph 1, item 2 of the Law on the State Agency for National Security and Article 19e, paragraph 1, item 2 of the Special Intelligence Means Act). The appointing authority announces a competition for the vacant positions designated for people with permanent disabilities at least once every 4 months. The Employment Promotion Act The Employment Promotion Act315 provides for measures for the unemployed and promotion of employment, provision of services for mediation to access employment, vocational training and guidance including people with disabilities. Like other acts, as described above, this Act also prohibits expressly any direct and indirect discrimination, privileges or restrictions. For every job that employs an unemployed person with permanent disabilities up to the age of 29, including military invalids, as well as young people using social or integrated health and social services for residential care, who have completed their education and are referred by a local branch of the Employment Agency, the employer is provided a wage subsidy for up to 18 months. An unemployed person with disability registered with the Employment Agency may apply for supported employment as well. The Act defines disadvantaged groups on the labor market as groups of unemployed persons with lower competitiveness in the labor market, including: unemployed youth, unemployed youth with permanent disabilities, unemployed youth in residential care, graduates, long-term unemployed, unemployed people with permanent disabilities, unemployed single parents (adoptive parents) and/or mothers (adoptive mothers) with children under 5, unemployed persons serving a prison sentence, unemployed over 50 years of age, unemployed persons with primary or lower education and no professional qualification, other groups of unemployed persons. Corporate Income Tax Act The Corporate Income Tax Act316 provides for earmarking of the corporate tax of legal entities holding the status of specialized enterprises, cooperatives and separate production units affiliated with national organizations of people with disabilities and organizations of people with disabilities. The earmarked funds are used for rehabilitation and social integration of people with disabilities. 314 The Civil Service Act. https://lex.bg/laws/ldoc/2134673408 315 The Employment Promotion Act. https://lex.bg/laws/ldoc/-12262909 316 The Corporate Income Tax Act. https://www.lex.bg/laws/ldoc/2135540562 193 Personal Income Tax Act People with disabilities who receive income from employment enjoy tax benefits under the terms and conditions set out in the Personal Income Tax Act.317 Local Taxes and Fees Act According to the Local Taxes and Fees Act,318 municipalities are obliged to ensure accessible built environment in kindergartens and schools, accessible public transport by adapting existing means of public transport and commissioning vehicles that are technically adapted for use by persons with disabilities, and special transport services for people with disabilities. The nationally represented organizations of persons with disabilities and for persons with disabilities are exempt from local taxes. The Road Traffic Act The Road Traffic Act319 sets out requirements for a card entitling its holder to park at parking spaces allocated to vehicles serving people with disabilities. The card is issued by a mayor of a municipality or by an official authorized by him/her. The card is standardized and valid across the country. Pre-School and School Education Act The right to education is guaranteed by the Constitution of the Republic of Bulgaria. In accordance with this principle, there is a provision for mandatory schooling up to 16 years of age. Primary and secondary education in state and municipal schools is free of charge. The state promotes education by opening and financing schools, by supporting gifted pupils and students with learning difficulties, creating conditions for vocational education and training. There is an opportunity for integrated education for children with special educational needs by creating a supportive environment in kindergartens and schools. Equal access to education for children with special educational needs and/or chronic diseases and their inclusion in mainstream schools is guaranteed by the Pre-School and School Education Act.320 The Act regulates inclusive education as an integral part of the right to education. It introduces an obligation to ensure support for personal development of all children and pupils. The Act describes inclusive education as a process of awareness, acceptance, and support for individuality of each child or a student and for diversity of needs of all children and students by activating and including resources aimed at removing barriers to learning and creating opportunities for development and participation of children and students in all aspects of community life. Individual support as a responsibility of kindergartens and schools is provided for all, not just for children with special educational needs. Higher Education Act The Higher Education Act321 provides favorable conditions for access, support, and integration in higher education for persons with disabilities and reduced work capacity of 70 percent and over through admission under eased conditions, if they have successfully passed the admission 317 The Personal Income Tax Act. https://www.lex.bg/laws/ldoc/2135538631 318 The Local Taxes and Fees Act. https://www.lex.bg/laws/ldoc/2134174720 319 The Road Traffic Act. https://lex.bg/laws/ldoc/2134649345 320 The Pre-school and School Education Act. https://www.lex.bg/bg/laws/ldoc/2136641509 321 The Higher Education Act. https://lex.bg/laws/ldoc/2133647361 194 examinations; special assistance provided for in the rules of higher education institutions, and exemption from tuition fees at state universities. Medical Devices Act The Medical Devices Act322 regulates rules for placing on the market and/or putting into operation medical devices; obligations of manufacturers or importers of medical devices or their authorized representatives; conditions and the order for carrying out clinical trials of medical devices; conditions and procedure for carrying out trade in medical devices; supervision of the market of medical devices; a system for notification and assessment of incidents/potential incidents related to medical devices. The Act’s objective is to ensure that medical devices do not endanger life and health of patients, medical professionals or third parties when devices are used for their intended purpose and are appropriately stored, distributed, installed, implanted and maintained, in accordance with the manufacturers' instructions; to ensure the application of the EU Commission Implementing Regulation № 920/2013 of 24 September 2013 on the designation and monitoring of notified bodies under Council Directive 90/385 / EEC on active implantable medical devices and Directive 93/42 / EEC of the Council on medical devices (OJ L 253/8 of 25 September 2013).323 Spatial Planning Act The Special Planning Act324 is one of the three laws regulating accessible environment for people with disabilities. The other two are the Persons with Disabilities Act and the Anti-Discrimination Act (see above). The Special Planning Act regulates relations associated with planning, investment planning and construction in Bulgaria. The Act governs overall process of investment planning, building permits and commissioning of buildings. Article 169(1)-(3) sets out requirements for buildings in terms of design, implementation, and maintenance. Electronic Communications Act The Electronic Communications Act325 is the main legislation regulating electronic communications services in Bulgaria. This law ensures the application of the EU regulatory framework for electronic communications networks and services. Physical Education and Sports Act The development of physical education and sport for people with disabilities is regulated by the Physical Education and Sports Act326 in accordance with the principles and standards of EU law, whereby physical education, sport and tourism in pre-school, mainstream, special and vocational schools is an integral part of the educational and training process. These are included in the curricula of the Ministry of Education and Science in coordination with the Ministry of Youth and Sports. Physical education and sports for people with disabilities aim at improving their quality of life and their rehabilitation and social integration. The Ministry of Youth and Sports (MYS) supports by targeted funds preparation and participation of athletes with disabilities in the Paralympics Games, World and European championships; it supports activities of sports organizations associated with 322 The Medical Devices Act. https://www.lex.bg/laws/ldoc/2135555444 323 The Implementing Regulation (EU) /201 920/2013. https://eur-lex.europa.eu/legal- content/EN/TXT/?uri=CELEX%3A32013R0920 324 The Spatial Planning Act. https://www.lex.bg/laws/ldoc/2135163904 325 The Electronic Communication Act. https://www.lex.bg/laws/ldoc/2135553187 326 The Physical Education and Sports Act. https://www.lex.bg/bg/laws/ldoc/2137187621 195 adapted physical activity for people with disabilities. Athletes with disabilities have free access to state and municipal sports facilities and do not pay for tickets for competitions. The MYS develops, coordinates implementation and funds program to promote, improve and maintain mobility opportunities through physical exercise and sports. Protection and Development of Culture Act The right of access to national and universal cultural values, the right to personal culture development, freedom of artistic, scientific, and technological creativity, innovation and copyright, and related rights are recognized and protected by Article 54 of the Constitution of the Republic of Bulgaria. Accordingly, the Protection and Development of Culture Act327 introduced the principles of democratic cultural policy, freedom of artistic creation and avoidance of censorship, equality of artists and cultural organizations, promotion of cultural diversity while preserving the unity of national culture, discovering, supporting, and training young talents in the field of culture and development and improvement of education in the arts and culture. 2. SECONDARY LEGISLATION Decree on Determining Methodology for Performing an Individual Assessment of the Needs for Support for People with Disabilities:328 The Methodology regulates preparation of an individual assessment of the needs of people with disabilities, including an assessment of the need for social services, personal assistance, or other types of support. It is based on the bio-psycho-social model of disability, in compliance with the World Health Organization International Classification of Functioning, Disabilities and Health (ICF). The purpose of the individual needs assessment (INA) is to obtain detailed information about the situation regarding participation of a person with disabilities in society and to establish her/his individual needs for support. The methodology, in accordance with the ICF, covers the following nine areas of life: learning and application of knowledge; general tasks and requirements; communication; mobility; self-care; household life; interpersonal interactions and relationships; main areas of everyday life; civil and public life. The INA should be: (i) transparent and objective, ensuring participation of a person whose needs are assessed, using objective tools and keeping relevant documents; (ii) inter-institutional (the needs of the person with a disability and the measures for providing support must be determined comprehensively); (iii) inter-disciplinary - depending on a specific case, other specialists or experts may be invited; (iv) oriented towards acceptance - support measures should be agreed on with the person whose needs are assessed, ensuring clarity and transparency and in accordance with his or her wishes and goals. It should also: (v) follow individual approach - all steps within individual assessment must be personally adapted to the needs of a person with disability; (vi) follow personal orientation - to guarantee the principle of personal orientation, the life of the person with disability, her/his specific life circumstances, as well as her/his experience must be known; all these should be taken into account when identifying the needs and in the planning of necessary support measures; (vii) consider external factors - taking into account factors of the environment in determining the needs; this also applies to the provision of specific measures to support and document relevant factors and barriers in this area; and (viii) be purposefull - providing adequate support for a person with disability. 327 The Protection and Development of Culture Act. https://www.lex.bg/laws/ldoc/2134664704 328 Decree № 64/29.03.2019 on Determining Methodology for Performing an Individual Assessment of the Needs for Support for People with Disabilities. https://www.lex.bg/bg/laws/ldoc/2137192215 196 Ordinance for the Inclusive Education (Council of Ministers),329 regulates the State Educational Standard for Inclusive Education, i.e., it determines conditions and the order for providing general support for personal development of children and pupils in kindergarten and school. It is adopted to support individual development of children and students with special educational needs. The Standard determines structure, conditions and order for: (i) approval of individual curricula for students with special educational needs; (ii) admission to and organization of education for children and students with special educational needs in special schools for students with sensory disabilities; (iii) education of children and students in a center for special educational support; (iv) referral of students with special educational needs who will receive a certificate for completed grades VII and X and for continuing their vocational education. The Ordinance regulates that children and students in pre-school and school education are provided with general and additional support for personal development to ensure appropriate physical, psychological and social environment for development of their abilities and skills. The support should be based on individual educational needs of each child and student and should be provided in kindergartens, schools, and centers for support for personal development; in some particular cases, it could be provided at home or in a medical institution. To implement individual support for personal development, the Ordinance provides for professional support by psychologists, pedagogical advisors, speech therapists, resource teachers and other specialists according to the students’ needs. General support for personal development is provided by teachers and by other pedagogical specialists. Additional support for personal development is provided depending on the support plan in which additional support activities for personal development and necessary specialists are specified. The Ordinance stipulates that an assessment of individual needs for additional support for personal development of children and students should be based on functional ability, which is defined as a consequence of the interaction between a health condition and the environmental factors, in accordance with the ICF and taking into account the WHO International Classification of Diseases - ICD 10. The assessment is carried out following a Card for Assessment of Individual Needs of a Child or a Student. The assessment is multidisciplinary, where the filling out of the separate sections of the Card are coordinated between specialists conducting the assessment. The result is an assessment about the functional ability of the child and necessary additional support for her/his development. Parent/s is/are involved in the assessment from the beginning and should express in writing in the assessment card their consent or disagreement with the assessment and proposed additional support for personal development of their child. The assessment card is part of the personal educational file of the child/student in the National Electronic Information System for Preschool and School Education and it follows the child/student in cases of transition from one pre- or school institution to another. Every child/student with special educational needs, for which through the assessment of her/his individual needs a need for resource support has been established, has the right to a support from a resource teacher. The Ordinance also provides for different types of professional assistance to support inclusive education, depending on the individual child/student’s needs as follows: 329 The Ordinance for Inclusive Education. https://www.lex.bg/en/laws/ldoc/2137177670 197 • in the case of sensory and/or neurological disabilities and multiple disabilities - resource teacher, hearing and speech rehabilitator, teacher of visually impaired children and students, speech therapist, psychologist, teacher's assistant, • in case of learning difficulties - speech therapist, psychologist, resource teacher, • in case of manifestations of the autistic spectrum disorder - resource teacher, speech therapist, psychologist, and if necessary - sensory therapist and teacher's assistant, • in case of emotional and/or behavioral difficulties - psychologist and/or pedagogical counsellor, and if necessary - teacher's assistant and psychotherapist, • in case of a child at risk - psychologist and/or pedagogical advisor, and if necessary - teacher's assistant and educational mediator from the community of the child or student or social worker, • in case of manifested gifts and abilities in different fields - teacher and/or specialists according to the manifested gifts and abilities of the child or the student, and if necessary - pedagogical advisor and/or psychologist, • in case of chronic diseases - hospital teacher, resource teacher, psychologist and/or pedagogical advisor. Ordinance for Medical Expertise (Council of Ministers),330 defines the medical expertise as an integral part of the medical diagnostic, as well as a prophylactic activity of the medical establishment. It determines the principles and criteria for a medical expertise, i.e., an assessment of disability and the order for its implementation. For work capacity, medical expertise includes: (i) the expertise (assessment) of permanently reduced work capacity, including the determination of its degree in percentages (as compared to a healthy person); (ii) an assessment of the need for assistance from other people and terms of that assistance; (iii) a decision on the duration of permanently reduced work capacity/disability and dates of its beginning and expiration; (iv) an opinion on the causality between the impairment and related incapacity for work in cases of a work accident, occupational disease and military disability; (v) an opinion on the causal link between the injury (death) and the working conditions (work performed) during the accident; (v) an assessment on whether a person is able to continue performing her/his job, need for employment and related accommodation. For disability, the expertise covers: (i) determination of the degree of disability in percentages compared to a healthy person; (ii) the need for assistance by others and the terms of such assistance; (iii) a decision on the duration of disability and dates of its beginning and expiration; and (iv) recommendations for further monitoring and rehabilitation. By Order № RD 01 - 364 of 22.05.2019, the Minister of Labor and Social Policy approves the list of medical devices for people with disabilities.331 Order № RD 01 - 365 of 22.05.2019 of the Minister of Labor and Social Policy determines a maximum amount of targeted aid for manufacturing, purchase and/or repair of assistive and technical tools, devices, equipment, and medical devices for people with disabilities. 332 330 The Ordinance for Medical Expertise. https://www.lex.bg/en/laws/ldoc/2137150573 331 The Order № RD 01 - 364 of 22.05.2019 of the Minister of Labour and Social Policy about the list of medical devices for people with disabilities. https://ahu.mlsp.government.bg/portal/document/67765 332 Order № RD 01 - 365 of 22.05.2019 of the Minister of Labour and Social Policy about the maximum amount of targeted aid for manufacturing, purchase and/or repair of supportive tools, devices, equipment, and medical devices for people with disabilities. https://ahu.mlsp.government.bg/portal/document/67766 198 Order № RD 01 - 366 of 22.05.2019 of the Minister of Labor and Social Policy approves the list of supportive technical aids, equipment, and devices for people with disabilities.333 Order № RD 09-296 of 24.08.2007 of the Minister of Health for determining a list of medical devices that can be sold in places other than the places under Article 83, paragraph 1 of the Medical Devices Act.334 The Ordinance No 2 of 15 March 2002 setting out conditions and procedures for approval of transport schemes and provision of public transport to passengers335 lays out requirements for municipal councils designating urban and intercity lines and their routes that involve buses for transportation of disabled persons and persons with reduced mobility with the following breakdown: 35 percent of the total number of runs - for transportation by bus lines and 35 percent of the total number of runs on the lines of municipal, regional and national transport system from the quota of the municipality - for transport on long distance lines. Tenders for the award of bus line transport services include a requirement to equip vehicles for the transport of disabled persons and persons with reduced mobility. In cities with population of over 100,000 residents, there should be at least one primary and one additional line which are served entirely by buses equipped to transport disabled persons and persons with reduced mobility. Transport companies are obliged to provide unimpeded access to buses for people with disabilities accompanied by guide dogs. Ordinance No 33 of 3 November 1999 for public transportation of passengers and goods on the territory of the Republic of Bulgaria336 sets out requirements for each bus station, which must have an external answering machine accessible to people with reduced mobility; a lifting platform or a ramp for wheelchairs in line with requirements for accessibility, which should provide access to buses; an accessible route from the street to the bus station and at the bus station to the bus; and in the waiting room, accessibility to ticket counters and at least one accessible public toilet. Ordinance No H-32 of 16 December 2011 for the regular inspections of the roadworthiness of vehicles337 sets technical requirements for buses to transport disabled persons and persons with reduced mobility and procedures for verification of the compliance with these requirements. Regulatory requirements (minimum standards) for the design, construction and maintenance of accessible built environment are set out in the Ordinance No 4 of 2009 for design, implementation, and maintenance of buildings in accordance with the requirements for accessible environment for the population, including people with disabilities.338 The Ordinance provides the following definitions related to accessibility: 333 Order № RD 01 - 366 of 22.05.2019 of the Minister of Labour and Social Policy approves the List of supportive tools, equipment, and devices for people with disabilities. https://ahu.mlsp.government.bg/portal/document/67767 334 Order № RD 09-296 of 24.08.2007 of the Minister of Health for determining the list of medical devices that can be sold in places other than the places under Article 83, paragraph 1 of the Medical Devices Act. https://ahu.mlsp.government.bg/portal/document/118 335 Ordinance No 2 of 15 March 2002 setting out conditions and procedures for approval of transport schemes and provision of public transport to passengers. https://www.lex.bg/laws/ldoc/-548912640 336 The Ordinance No 33 of 3 November 1999 for public transportation of passengers and goods on the territory of the Republic of Bulgaria. https://lex.bg/en/laws/ldoc/-549663744 337 The Ordinance No H-32 of 16 December 2011 for the regular inspections of the roadworthiness of vehicles. https://www.lex.bg/laws/ldoc/2135766401 338 Ordinance No 4 of 2009 for design, implementation and maintenance of buildings in accordance with the requirements for accessible environment for the population, including people with disabilities. https://www.lex.bg/laws/ldoc/2135639181 199 • People with reduced mobility are people who have permanent or temporary mobility difficulties. They include: people with disabilities of the musculoskeletal system, body and/or lower limbs, as well as the body and upper limbs, including people who can move with or without technical aids (cane, crutches, frame) and/or with a manual or mechanical wheelchair; people with hearing and vision impairments, including people with partially or completely impaired vision who orient themselves relying entirely on their hearing, touch and smell; people with partially or completely impaired hearing who orient themselves relying entirely on their sight, touch and smell; and people with partial or complete impaired vision and hearing; people with inability to adequately perceive and assess their environment, who due to mental illness or mental retardation have difficulty or limited capacity in a not adapted urban environment; people with combined previously listed disabilities. • Accessible environment is an environment in urban areas, buildings, and facilities, which every person with reduced mobility, with or without disabilities can use freely and independently. • Accessible route in urbanized environment is a route, which all people can use freely and independently, considering specific needs of people with reduced mobility, including people with disabilities, which connects pedestrian areas, intersections, footpaths, bus stops of regular public passenger transport lines, and features curbs, accessible parking spaces and other accommodation needed for an accessible environment. • Accessible entrance is an entrance that can be used independently by all people, considering specific needs of people with reduced mobility, including people with disabilities. • Accessible route to a built environment is an accessible route from streets and pedestrian areas, vehicle stops for regular public passenger transport lines, boarding areas and accessible parking lots to accessible entrances of public service buildings, facilities or residential buildings. • Danger zones are common premises, the entry into which may cause slips, falls, shocks, burns, electric shocks, explosions (premises for electrical and thermal installations, water heating devices and heating installations). • Non-slipping surface is a finished surface in which the friction with a shoe or with a moving device is maintained at an acceptable level in dry and wet conditions. • Accessible information card is a card that can be read by a wide range of people with reduced mobility, including from people with disabilities. • Accessible website is a website that can be used by people with visual, mental, and psychological disabilities and by foreigners. • Tactile signs and tactile controls are signs or controls with prominent pictograms, symbols, or Braille. The Ordinance No 6 of 13 March 2008 on universal service under the Electronic Communications Act339 issued by the State Agency for Information Technology and Communications pursuant to Article 182(3) and in conjunction with Article 193 of the Act. Article 16 of Section VI "Special measures for people with disabilities" of the Ordinance stipulates actions aimed at ensuring equal access to public telephone services for people with disabilities, including: free advice on technical characteristics of electronic communications terminal equipment; free connection to the "call barring" service; facilities for users of impaired vision by relief "PIP" sign button 5 as a benchmark for public phones; location of the chip or a sign indicating recognition of the direction to place any calling card or other type of card for electronic payment; special phones and/or telephones in public areas installed in suitable locations available to users in wheelchairs in hospitals, sanatoria, headquarters of organizations of people with 339 Ordinance No 6 of 13 March 2008 on universal service under the Electronic Communications Act. https://www.lex.bg/bg/laws/ldoc/2135583839 200 disabilities and other places, as well as public phones with text or other connection means for persons who are deaf or hearing and/or speech impaired; free and in an appropriate form itemized bills (on request); telephone directory inquiry services and contracts in appropriate form (on request); etc. The Ordinance № RD-07-8 of July 24, 2019, on conditions and procedures for implementation and control of the provision and repair of auxiliary equipment, accessories and facilities, and repair of aids, supportive devices, facilities, and medical devices for people with disabilities340, issued by the Minister of Labor and Social Policy. The Ordinance defines criteria and requirements for the provision and repair of aids, devices, equipment, and medical devices for people with disabilities, as well as requirements related to persons providing and repairing aids, devices, equipment and medical devices for people with disabilities. Ordinance of the Sofia Municipal Council for building public environment in Sofia341 determines specific rules and norms, supplementing construction requirements of the City of Sofia to ensure that Sofia urban environment can be used by all groups of the population, including people with disabilities. According to this Ordinance, the Sofia City Council must adopt annual programs and provide budget funds to implement measures for accessibility in Sofia. The Ordinance of the Burgas Municipal Council for stopover and parking of vehicles driven by or transporting people with permanent disabilities on the territory of the Municipality of Burgas, at the municipal-owned car parking areas.342 The Ordinance determines that a certain number of places for preferential parking of vehicles transporting people with permanent disabilities must be provided in open, covered, underground, multi-story and mixed types of parking spaces and in the zones for hourly paid parking. The Ordinance № RD-07-6 of 20.06.2019 on the procedure for exercising control over spending of funds from the reimbursed social security contributions of employers, civil service appointing authorities, specialized enterprises, and cooperatives of people with disabilities and occupational health facilities.343 This Ordinance regulates control and disclosure of information about spending of reimbursed social insurance contribution on investment and rehabilitation. Agency for People with Disabilities exercises control over the regulation implementation. 340 Ordinance № RD-07-8 of 24 July 2019 on conditions and procedures for implementation and control of the provision and repair of auxiliary equipment, accessories and facilities, and repair of aids, supportive devices, facilities, and medical devices for people with disabilities, issued by the Minister of Labour and Social Policy. https://www.lex.bg/bg/laws/ldoc/2137195307 341 The Ordinance of Sofia Municipal Council for building public environment in Sofia. https://sofia.obshtini.bg/doc/105032 342 The Ordinance of Burgas Municipal Council for stopover and parking of vehicles driven by or transporting people with permanent disabilities on the territory of the Municipality of Burgas, at the municipal-owned car parking areas. https://burgascouncil.org/node/1325 343 The Ordinance № RD-07-6 of 20.06.2019 on the procedure for exercising control over spending of funds from the reimbursed social security contributions of employers, civil servants appointing authorities, specialized enterprises, and cooperatives of people with disabilities and occupational health facilities. https://lex.bg/bg/laws_stoyan/ldoc/2137194194 201 Annex 3: List of Legal Acts Pertaining to Disability with Active Links The Constitution of the Republic of https://lex.bg/laws/ldoc/521957377 Bulgaria The People with Disabilities Act https://www.lex.bg/bg/laws/ldoc/2137189213 The Anti-Discrimination Act https://www.lex.bg/laws/ldoc/2135472223 The Social Services Act https://www.lex.bg/bg/laws/ldoc/2137191914 The Child Protection Act https://www.lex.bg/laws/ldoc/2134925825 The Health Act https://www.lex.bg/laws/ldoc%20/2135489147 The Personal Assistance Act https://www.lex.bg/bg/laws/ldoc/2137189250 The Medical Establishments Act https://www.lex.bg/laws/ldoc/2134670848 The Health Insurance Act https://www.lex.bg/laws/ldoc/2134412800 The Social Security Code https://www.lex.bg/laws/ldoc/1597824512 The Labor Code https://www.lex.bg/laws/ldoc/1594373121 The Civil Service Act https://lex.bg/laws/ldoc/2134673408 The Employment Promotion Act https://lex.bg/laws/ldoc/-12262909 The Corporate Income Tax Act https://www.lex.bg/laws/ldoc/2135540562 The Personal Income Tax Act https://www.lex.bg/laws/ldoc/2135538631 The Local Taxes and Fees Act https://www.lex.bg/laws/ldoc/2134174720 The Road Traffic Act https://lex.bg/laws/ldoc/2134649345 The Pre-School and School https://www.lex.bg/bg/laws/ldoc/2136641509 Education Act The Higher Education Act https://lex.bg/laws/ldoc/2133647361 The Medical Devices Act https://www.lex.bg/laws/ldoc/2135555444 The Spatial Planning Act https://www.lex.bg/laws/ldoc/2135163904 The Electronic Communications Act https://www.lex.bg/laws/ldoc/2135553187 The Rules for the Implementation of https://www.lex.bg/bg/laws/ldoc/2137192229 the Law on People with Disabilities Decree № 64/29.03.2019 https://www.lex.bg/bg/laws/ldoc/2137192215 determining the Methodology for Performing an Individual Assessment of the Needs for Support for People with Disabilities Ordinance for the Inclusive https://www.lex.bg/bg/laws/ldoc/2136927891 Education adopted by the Council of Ministers Ordinance for the Medical https://www.lex.bg/en/laws/ldoc/2137150573 Examination adopted by the Council of Ministers 202 Order № RD 01 - 364 of 22.05.2019 https://ahu.mlsp.government.bg/portal/document/67765 of the Minister of Labor and Social Policy about the list of medical devices for people with disabilities Order № RD 01 - 365 of 22.05.2019 https://ahu.mlsp.government.bg/portal/document/67766 of the Minister of Labor and Social Policy about the maximum amount of targeted aid for manufacturing, purchase and/or repair of supporting tools, devices, equipment, and medical devices for people with disabilities Order № RD 01 - 366 of 22.05.2019 https://ahu.mlsp.government.bg/portal/document/67767 of the Minister of Labor and Social Policy determining the List of supporting tools, equipment, and devices for people with disabilities Order № RD 09-296 of 24.08.2007 https://ahu.mlsp.government.bg/portal/document/118 of the Minister of Health for determining the List of medical devices that can be sold in places other than the places under Article 83, paragraph 1 of the Medical Devices Act Ordinance №RD-07-6of 20 https://lex.bg/bg/laws/ldoc/2137194194 June2019on the procedures for exercising control over spending of reimbursed contributions to employers, respective bodies of appointment, specialized enterprises, and cooperatives of people with disabilities Ordinance No 2 of 15 March 2002 https://www.lex.bg/laws/ldoc/-548912640 setting out the conditions and procedures for approval of transportation schemes and the provision of public transport for passengers Ordinance No 33 of 3 November https://lex.bg/en/laws/ldoc/-549663744 1999 for public transportation of passengers and goods in the territory of the Republic of Bulgaria Ordinance No H-32 of 16 December https://www.lex.bg/laws/ldoc/2135766401 2011 for the regular inspections of the roadworthiness of vehicles Ordinance No 4 of 2009 for the https://www.lex.bg/laws/ldoc/2135639181 design, implementation, and maintenance of buildings in accordance with the requirements for accessible environment for the 203 population, including people with disabilities Ordinance No 6 of 13 March 2008 https://www.lex.bg/bg/laws/ldoc/2135583839 on universal service under the Electronic Communications Act Ordinance № RD-07-8 of 24 July https://www.lex.bg/bg/laws/ldoc/2137195307 2019 on the conditions and procedure for implementation and control of activities for provision and repair of auxiliary equipment, accessories and facilities, and repair of aids, supportive devices, and medical devices for people with disabilities, issued by the Minister of Labor and Social Policy Ordinance of the Sofia Municipal https://sofia.obshtini.bg/doc/105032 Council for building public environment in Sofia Ordinance of Burgas Municipal https://burgascouncil.org/node/1325 Council for stopover and parking of vehicles driven or transporting people with permanent impairments on the territory of the Municipality of Burgas, in the municipal-owned car parking areas 204 Annex 4: Specific Programs to Support Persons with Disabilities 1. Family allowance for children with disabilities Regulated by The Family Allowances Act (FAA), The Regulation on the Implementation of the Family Allowances Act Regulating agency Ministry of Labor and Social Policy (MLSP) Implementing agency Social Assistance Agency (SAA) of MLSP with its directorates at the municipal level Description A mother who has a child with disability has the right to a monthly allowance. Fathers can receive this allowance only with the written agreement from the mother. The goal of the allowance is to support the family care for children with disabilities. The allowance amount depends on the level of disability of the child. A mother is eligible for additional one-off payment for birth of a child with >50 percent of disability, as determined by a Territorial Medical Expert Commission (TMEC). Eligibility criteria To be eligible, a person needs to present an evaluation document from TMEC certifying the established degree of disability for children 0 to 16 years old, or, for children above 16 years of age, a degree of reduced work capacity >50 percent and to complete the application process. To receive the one-off payment for birth delivery, the child’s disability should be established before the child reaches the age of 2. Level of benefit The allowance and the one-off payment amounts are determined yearly by the National Budget Act of the Republic of Bulgaria. In 2020: • 3rd level disability (for children 0-16)/reduced work capacity >90 percent for children older than 16 until completion of secondary education, but not later than 20 years of age: 930 BGN for 2020. • 2nd level disability (for children 0-16)/reduced work capacity 70-90 percent for children older than 16 until completion of secondary education, but not later than 20 years of age: 450 BGN. • 1st level disability (for children 0-16)/reduced work capacity 50-70 percent for children older than 16 until completion of secondary education, but not later than 20 years of age: 350 BGN. The one-off payment: 100 BGN. Benefit delivery/payment Family allowance: monthly frequency One-off payment: when the child’s disability is certified. 205 Benefit duration and A duration of the benefit is related to the period of validity of the TMEC renewal requirements decision – most often 3 or 5 years. After the expiration of the TMEC decision the application procedure is repeated as for the first application. A one-off payment can be requested from the time the child’s disability has been certified, until the child turns 2. Application and decision Application: making An application should be submitted to a municipal Directorate of the Social Assistance Agency (in municipality where the applicant resides). An electronic submission of application is possible with a certified electronic signature. A proof of the current address of the parent and the child should be attached to the application. There is no requirement to submit the TMEC decision as it is verified internally. If the child is over 18, but still a student, a document from the school is required as well. Documents review and decision: Decision should be made within 14 working days after the application submission. If there is a need for corrections/additional information, 14 working days are given to the applicant to make corrections/provide additional information. The decision should be made within 30 days from the submission of correct application. There is no specific administrative process for the one-off payment. SAA receives information from TMEC about a child of up to two years of age with a certified disability. Grievance redress An appeal can be made to a director of the responsible Directorate of the SAA mechanisms or to the general Director of the Agency. Court appeal: an appeal can also be made to the relevant administrative court, following the Code of Administrative Procedure. The decision of the court is final. Monitoring arrangements The Inspectorate under SAA controls and monitors work of Directorates of SAA. Financing agency SAA Sources of financing State budget Disability social security pension and a supplement for assistance and care from other people Regulated by The Social Security Code, Regulation on pensions and social security Regulating agency MLSP, NSSI Implementing agency NSSI (National Social Security Institute) Description Working age persons with permanently reduced work capacity have the right to a disability pension. Disability pensions can be combined with receiving a 206 salary, when the person is working and receiving wages for their work. 344 In other words, receiving a disability pension does not preclude employment. Disability pensions are of two types: “Social disability pension” is provided to person with disability with no work experience and no social security contributions. For the social disability pensions a minimum of 71 percent of reduced work capacity is required. “Disability pension” is a pension provided based on work experience and paid social security contributions. The required minimum degree for a disability pension is 50 percent of reduced work capacity. For working age adults (18-64) the term “level of disability” is not applicable; instead, the term “level of reduced work capacity” is used. Both denote disability in the ICF terms. Disability pensions are divided into three main groups.345 Disability pension due to general illness. The person’s health condition causing work incapacity is not related to their occupation. Disability pension due to work accident or occupational illness – the pension is granted when work incapacity is the result of an accident at work or professional illness.346 Disability pension for military or civic duty related disability - the pension is granted to persons who have acquired work incapacity when on military or civic duties. Disability pension can be personal or survivor. An individual can receive only one type of pension. A disability pension cannot be granted to a person who is receiving a pension based on the length of service (old age pension), however, he/she can be certified as disabled. A disability pension due to general illness can be granted to an individual who is receiving a social disability pension if she/he has accrued at least 1 year of work experience in full time employment of 8 working hours a day or 40 working hours a week. The work experience can also be counted cumulatively over a longer period. Once a recipient of social disability pension meets the required work duration/social security contribution coverage, she/he can request that her/his pension is changed to a disability pension due to general illness. Supplement for assistance and care from other people is an addition to a disability pension if a degree of disability is >90 percent. To receive this supplement, a disabled person needs to be granted a status of needing support and care by other people by TMEC together with the decision on the degree of work incapacity. TMEC also decides on the duration of the support. 344 Each person with a disability, regardless of the degree of her/his disability, has the right to work. This right is sometimes not respected when: (a) some TMECs still use “unfit for work” conclusion in disability certificate; and (b) due to a specificity of the illness, the employer considers that the performance of work duties poses a risk for the person’s health. 345 Additional subgrouping of disability pensions is available for persons who have the right to a pension according to special legal provisions and for persons in early retirement. 346 “Professional illness” is a disease resulting from harmful factors in the work environment or labor processes and is included in the list of professional illnesses approved by the Council of Ministers. Employees with a labor contract are insured against occupational disease/work accident through a Social Security Fund for Work Accidents or Professional Illness. 207 Eligibility criteria Certified disability by TMEC/NMEC as having a work incapacity >50% (and the need for assistance by others in the law stipulated cases – see above). Proof of work experience and social security coverage. The National Social Security Institute has a medical commission that reviews TMECs’ decisions on reduced work capacity/disability and its severity and the need for support and care from other people. Eligibility criteria for granting disability pension include: For disability pension due to general illness If disability had been acquired at birth or before starting work experience: certified disability degree of >50 percent and at least one year of work experience. For visually impaired persons by birth or before starting work up to 20 years of age, work experience is not required. For people not experiencing disability prior to reaching 25 years of age, a minimum of 1 year of work experience is required. For people not experiencing disability prior to 30 years of age, a minimum of 3 years of work experience is required. For people who have acquired disability after 30 years of age, a minimum of 5 years of work experience is required. For disability pension due to work accident or occupational illness Confirmed work accident or occupational illness with a resulting reduced work capacity of >50percent. For social disability pension (no work experience) A person should be above 16 years of age with certified reduced work capacity /degree of disability >71percent. Supplement for support from other people: certified degree of disability >90 percent and a TMEC decision that she/he needs permanent support by other people. Level of benefit The amount depends on the type of pension, a degree of disability, length of work experience (when required) and the basis used for calculation of the type of disability pension. The minimum level of disability pension is calculated based on the minimum old-age pension determined annually by the Council of Ministers. Disability pension due to general illness: For >90 percent disability: 115 percent of the minimum old-age pension - from January 1, 2020, = 252.34 BGN, and from July 1, 2020, = 287.50 BGN. For 71-90 percent disability: 105 percent of the minimum old-age pension – from January 1, 2020, = 230.40 BGN, and from July 1, 2020, = 262.50 BGN. For 50-70.99 percent disability: 85 percent of the minimum old-age pension – from January 1, 2020, = 186.52 BGN, and from July 1, 2020, = 212.50 BGN. Disability pensions due to work accident or occupational illness: For >90 percent disability: 125 percent of the minimum old-age pension - from January 1, 2020, = 274.29 BGN, and from July 1, 2020, = 312.5 BGN. 208 For 71-90 percent disability: 115 percent of the minimum old-age pension – from January 1, 2020, = 252.34 BGN, and from July 1, 2020, = 287.5 BGN. For 50-70.99 percent disability: 85 percent of the minimum old-age pension – from January 1, 2020, = 186.52 BGN, and from July 1, 2020, = 212.50 BGN. The actual amount of disability pension is calculated considering the months of work covered by insurance multiplied with a coefficient that depends on the degree of disability but cannot be lower than the minimum pension as listed above. Social disability pension:347 For a degree of disability above 90 percent - 120 percent of the old-age pension348 – from January 1, 2020, = 159.29 BGN, and from July 1, 2020, = 169.50 BGN. For a degree of disability of 71-90 percent - 110 percent of the old-age social pension – from January 1, 2020, = 146.01 BGN, and from July 1, 2020, = 155.79 BGN. The supplement for support by others = 75 percent of the old-age social pension, as a supplement to the person’s disability pension (regardless of the type of pension); since July 1, 2020, = 106 BGN. Benefit delivery/payment Monthly frequency Benefit duration and The pension is granted for the period of the TMEC’s decision validity. In case of renewal requirements renewal, the payment resumes from the month in which it was suspended. For persons in retirement age349 (at the time of this Report preparation: above 61 for women, and above 64 for men), the pension is granted for life. Application and decision Application procedure: making An application form is submitted to the territorial office of the National Social Security Institute, according to the person’s permanent or current address. There is a list of required originals of documents, including the decision by TMEC should be attached to the application. When the application is submitted for the first time, a pension file is created. During the application review, additional information can be requested. The file is reviewed by a commission of the relevant NSSI office. The commission should decide within 14 days from the date of receiving medical documents. The commission must approve or appeal the decision of the TMEC. After the review has been completed, decision is issued as an order by the Head of the territorial office of NSSI. The applicant is required to sign the order too. Grievance redress Complaint to the Head of the NSSI office mechanisms Complaint to the head of the NSSI Appeal of the decision of the Head of the NSSI to the administrative court 347 Persons with disability 50-70.99 percent due to general illness are not entitled to a social disability pension. 348 The old-age social pension is 141.63 BGN per month (from July 1, 2020), determined by the Council of Ministers. 349 The retirement age is being increased gradually until 2037. 209 Monitoring arrangements The Inspectorate of NSSI controls the work of employees according to their functions and obligations. Financing agency NSSI Sources of financing National social security budget 2. Social assistance to adults with disabilities Regulated by Persons with Disabilities Act, Regulation on the Implementation of the Persons with Disability Act, Individual assessment methodology Regulating agency MLSP Implementing agency SAA Description Monthly financial support for persons with disabilities to compensate the expenses related to overcoming limitations resulting from the type and degree of disability and depending on their needs, as defined in the individual needs assessment. The allowance is awarded to all permanently disabled persons above the age of 18350 and it depends on the degree of disability determined by TMEC/NMEC. The allowance differentiates between the following groups of persons with permanent disability: 1. persons with 50-70.99 percent degree of disability 2. persons with 71-90 percent degree of disability 3. persons with >90 percent degree of disability 4. persons with >90 percent degree of disability, entitled to receive assistance support from other people who are receiving disability pension due to general illness or due to work accident or occupational illness 5. persons with >90 percent degree of disability, entitled to assistance support from other people receiving social disability pension. Eligibility criteria Certified disability Older than 18 Persons with permanent disabilities between the age of 18 and 20 can receive this allowance if they do not benefit from the family allowance for children with disabilities. Completed individual needs assessment (INA) process. In the case of this allowance, INA is a formality, because the right to receive it depends exclusively on the degree of disability, determined by TMEC. 350 According to the Persons with Disabilities Act, permanently disabled persons are individuals with a permanent physical, mental, intellectual, or sensory deficit, which in interaction with the environment could impede their full and effective participation in social life, and for whom an expert medical assessment has ascertained a type and degree of disability or a degree of permanently reduced work capacity of at least 50 percent. 210 Level of benefit The amounts are as follows (2020): 6. For a degree of disability 50-70.99 percent: 7 percent of the poverty line351 (25.41 BGN), 7. For a degree of disability 71-90 percent: 15 percent of the poverty line (54.45 BGN), 8. For a degree of disability >90 percent: 25 percent of the poverty line (90.75 BGN), 9. For a degree of disability >90 percent + care by others + disability pension due to general illness /work accident/ occupational illness: 30 percent of the poverty line (108.90 BGN), 10. For a degree of disability above 90 percent + care by others + social disability pension: 57 percent of the poverty line (206.91 BGN). Benefit delivery/payment Monthly frequency Benefit duration and For the period of validity of the TMEC’s decision. renewal requirements 5 years, if the TMEC decision is for life and in the cases when the type and degree of disability or permanently reduced capacity to work have been established after a person had reached the age required for the contributory old-age pension but within the period of the decision of the TMEC (or NMEC).352 Up to 3 months, if the medical documents do not state a period. Application and decision Application procedure: making Application by a person with a disability or his or her legal representative to the SAA municipal office, according to the person’s current address. The following documents need to be attached to the application: (a) a copy of completed self-assessment form with filled in sections required for this benefit and (b) a copy of the TMEC decision. The application can be submitted in person/by post mail/by courier. Electronic submission is possible only with an electronic signature. Review and decision: If some information is missing, the applicant is given 14 days to correct the situation. A social worker is assigned to the person. He/she prepares an individual needs assessment with an obligatory contact with the applicant. 351 The poverty line is determined annually by the Council of Ministers following an official methodology. For 2020, the poverty line was 363 BGN. 352 The Persons with Disabilities Act (2018) introduced the terms “people with disabilities” and “permanently disabled people”: (i) "People with disabilities" shall mean persons with a phys ical, mental, intellectual, or sensory deficit, which in interaction with the environment could impede their full and effective participation in social life. (ii) "Permanently disabled people" shall mean persons with a permanent physical, mental, intellectual, or sensory deficit which, which in interaction with the environment could impede their full and effective participation in social life, and for whom an expert medical assessment has ascertained a type and degree of disability or a degree of permanently reduced work capacity 50 and over 50 percent.” Ibid. 211 The social worker submits the case to a commission under a specialized department of the same SAA municipal office. The commission reviews the case and issues an order for granting the allowance. Grievance redress The order can be appealed within 14 days, following the Administrative mechanisms Processes Code. Monitoring arrangements MLSP Financing agency SAA (MLSP) Sources of financing State Budget through MLSP budget allocation 3. Targeted disability allowances Regulated by Persons with Disabilities Act (PDA), Regulation on Implementation of the APD Regulating agency MLSP Implementing agency SAA Description There are four types of targeted disability allowances, depending on the type of disability. They apply to both children and adults with disabilities. 1. Purchase of a personal motor vehicle for permanently disabled people with mobility difficulties. The benefit reimburses partially the cost of a car purchase. 2. Home adaptation for permanently disabled people using a wheelchair. The benefit reimburses some expenses for renovation of living space. 3. Rehabilitation and balneotherapy services, based on a need established by a medical specialist. The benefit covers expenses up to the set limit for a person with disabilities and the same (actual amount up to the set limit) for an accompanying person for those persons with disabilities who are with assigned assistance and care from other people. The benefit is paid based on documents confirming that therapy and/or rehabilitation had taken place. This targeted support can be used both in public and private establishments. When used in publicly owned rehabilitation centers – the amount is paid to a hospital/rehabilitation facility; in the case of a private facility – the funds are reimbursed to a person, after he/she has incurred the cost. 4. Payment of municipal housing rent for permanently disabled people living alone or for single parents with permanently disabled child/children residing in municipal housing. The rent is paid to municipality. Eligibility criteria Purchasing a personal motor vehicle (income tested): • >90 percent type and degree of disability/permanently reduced work capacity, • Persons are in employment or in education, • The car should be owned by a person with disability (beneficiary), her/his family, 212 • The monthly average income per member of a household in the last 12 months equal to or below the poverty line. Adaptation of a home (income tested): • >90 percent type and degree of disability, as well as children with a certain type and degree of disability, • Proof that a child or adult with disabilities uses a wheelchair for movement, • The monthly average income per member of a household in the last 12 months equal to or below the poverty line. Rehabilitation and balneotherapy service • Adults: >90 percent permanently reduced work capacity; permanently disabled children: =>50 percent disability, and disabled servicemen • A medical prescription for balneotherapy and/or rehabilitation according to their specific needs, Rent payment of municipal housing: • Degree of disability =>50 percent, • A permanently disabled person is single, • A single parent with a permanently disabled child with =/>50 percent disability, • A rental contract with a municipality for renting a dwelling in municipal housing (concluded with the permanently disabled person, or if he or she has been placed under full judicial disability - with his or her lawful representatives. To receive a targeted benefit, a person needs to go through INA. However, the INA has no impact on the decision (it does not serve as a base to establish eligibility). Level of benefit Purchase of a personal motor vehicle: up to four times the amount of the poverty line for the respective year (max of 1452 BGN for 2020). Adaptation of a home: up to two times the amount of the poverty line for the year during which the adaptation was made (726 BGN for 2020) Rehabilitation and balneotherapy service covers the actual expenses for rehabilitation as per the paid invoice, with the limit of 80 percent of the poverty line (290.40 BGN) for both the person with disability and the person who has accompanied her/him. Payment of municipal housing rent: amount of the rent according to the contract and regulations of the municipality. 353 Benefit delivery/payment Purchase of a personal motor vehicle: After the purchase of the car, the frequency person/family applies with relevant documents for reimbursement. The payment is made in the month following the month when the request was approved, in cash or via a bank transfer. 353 The rent amount is determined by the Municipal Property Act of the respective municipality. 213 Adaptation of home: Same as above. Rehabilitation and balneotherapy service: The allowance is paid based on the documents confirming therapy/rehabilitation. Payment: 10 days after confirming eligibility if private facility is used; or direct payment to the state- owned facility. In the second case, a person uses rehabilitation services based on an order, without paying. Municipal housing rent: Monthly transfer to municipality. Benefit duration and For personal motor vehicle: once in 5 years. renewal requirements For adaptation of home: once in 10 years. For balneotherapy and rehabilitation: once in a calendar year. For rent: for the period of validity of the TMEC decision, as long as the municipal housing is rented. All benefits require new application for the next period. Application and decision Application making An application should be submitted to a municipal SAA office, according to the person’s current address. Attached to the application: (a) completed self-assessment form filled in sections relevant for targeted disability allowances; (ii) a copy of the TMEC decision. According to the regulation, after the approval of the need based on INA, the applicant is required to submit additional document. 354 For purchase of a vehicle: A copy of the registration certificate for their personal motor vehicle, Documents proving the family’s gross income over the last 12 months, A proof of the vehicle purchase. For home adaptation: An itemized invoice for renovation and proof of payment, Documents proving the family’s gross income over the last 12 months, For balneotherapy/rehabilitation There are two options, depending on where the service is used. If the service is provided in a private establishment: medical prescription from a specialist for the need for balneotherapy and/or rehabilitation services, and an invoice and the proof of payment. If the service is to be provided by a state-owned establishment: medical prescription from a specialist for the need for these services. Subsequently, an order is issues within a 10-day period; the person presents the order to the state-owned establishment and uses the service. For public housing rent: 354 There is a practice of SAA to ask persons to submit all needed documents together with the application for INA, to save them time and efforts. 214 Rental contract. Approval and payment The processes include INA (within one month), a review of documents and eligibility requirements, a decision on the eligibility, issuance of an order and payment. Some allowance-specific steps include: (i) for the home adaptation, a site visit by the case manager (SAA employee) to verify that the adaptation and its purpose; (ii) for rehabilitation and balneotherapy service when the service is used in a state-owned facility, the service provider is required to submit certain documents to the SAA355; and (ii) for the municipal housing rental, a municipality sends the invoice to the responsible SAA office. 356 Grievance redress The decision can be appealed within 14 days, following the procedure of the mechanisms Administrative Processes Code. Monitoring arrangements MLSP Financing agency SAA Sources of financing State budget 4. Targeted support for technical aid medical equipment and reimbursement of transport costs incurred to acquiring them Regulated by Persons with Disabilities Act (APD) Regulation on the implementation of the APD; and Annex II to the Regulation Executive order of MLSP on determining the maximum amount of the targeted benefits for the respective types of medical equipment The Register of the Agency for Persons with Disabilities, listing the entities that provide and repair assistive technology, devices, and medical equipment for persons with disabilities357 Regulating agency MLSP Agency for Persons with Disabilities (APD) SAA 355 Before the 5th of the next month, a service provider should submit the following documents to the responsible SAA office, requesting a reimbursement: medical prescription, invoice (original) and a receipt listing all expenses incurred for the person with disability and her or his companion. The provider should certify that services were indeed used. The territorial directorate of SAA should reimburse the provider not later than the 25 th of the same month. 356 While the person is informed that she/he was granted the public housing rental allowance, all other issues (invoice, reimbursement, etc.) are handled internally between the municipality and the responsible SAA office. 357 Note that the registry of the providers of technical aids and medical devices to persons with disabilities was transferred from APD to the Executive Agency for Medicines as of January 2021. Effective January 1, 2022, with the latest amendments to the Persons with Disabilities Act (Article 89, para 8/ SG No. 105/December 11, 2020), the supervision of the provision of technical aids and medical devices to persons with disabilities will be transferred from APD to the Ministry of Health, National Health Insurance Fund, and the Executive Agency for Medicines. 215 Implementing SAA agency Description The benefit covers expenses to produce, purchase, and/or repair technical and medical aids. A person with disability receives technical/medical aid, not the money, except when the aid was acquired during the treatment abroad, or it concerns orthopedic footwear. In such cases, the APD reimburses via a bank transfer a person with disability after he/she submits requested documents. The list of aids, including the medical conditions, the operational terms and the necessary medical documents for the provision and their cost are determined by the Regulation on the Implementation of APD and Annex II to the Regulation, and the executive order of MLSP on determining the maximum amount of the targeted benefits. The technical and medical aids provider must be registered in the Register maintained by APD.358 Targeted benefit is provided to the eligible person for the production, purchase and / or repair of aids, devices, equipment and medical devices only by persons entered in the Register. A person with disability is also entitled to be reimbursed for travel expenses incurred within Bulgaria related to the acquisition of technical aids when they have not been available at her/his location. Eligibility criteria Completed individual needs assessment. Medical document, issued by TMEC or NMEC, prescribing necessary technical aids and their type. Proof that the technical aids provider is registered with APD. Proof that the cost is within the set limit. Level of benefit For technical aids: up to the ceiling per aid. For transport expenses – up to the amount of the actual expenses, evidenced by tickets. For a technical aid purchased abroad – based on the proof of purchase, up to the ceiling for the respective type of aid. Benefit The awarded benefit (“order”) is valid for three months (the aid must be obtained delivery/payment within this time limit). frequency The person receives her/his aid directly from the supplier upon submission of the order. A handover protocol should be signed by both parties. Travel expenses are reimbursed by the end of the month following the request. For each technical aid the renewal is based on the end of its service life, specified in Annex II to the Regulation on the Implementation of PDA. Benefit duration For aids whose renewal is linked to their service life, a new set of documents is not and renewal required. In other cases, the application process must be done anew.359 requirements 358 See the previous footnote. 359 The law requires that for each renewal, even a battery purchase, a person needs to go through INA. To mitigate this, the SAA decided to include an extra pack of batteries. 216 Usage and return policy: The beneficiary cannot replace, sell, or donate the aid during its service life. In case she/he stops using it, the aid must be returned to the Social Assistance Directorate. Application and Prior requirement:360 conclusion from INA that a person needs an aid. However, this decision making requirement is a formality because it is TMEC/NMEC that decides that a person needs a technical aid. Application After INA had been completed, a person or her/his representative must also submit the following documents to a relevant municipal SAA office: (i) a pro forma invoice (preliminary invoice) for the aid from a registered supplier and (ii) a document from a supplier, certifying that it is properly registered. 361 The SAA’s municipal office should issue an ord er for the technical aid benefit award within 10 working days from the submission of documents. After having received the order and the handover protocol, a person submits these to the supplier, receives the device and both parties sign the handover protocol. For the reimbursement of transport expenses, a request should be made within one month following the date when the aid was received with the following supporting documents attached: return tickets and a document from the supplier certifying the visit/examination. An order to reimburse the expenses should be issued within 7 days. Reimbursing the provider/supplier The aids supplier should submit a request for reimbursement to the municipal SAA office that has issued the order, attaching to it: an invoice, original order, and the signed handover protocol, as well as a proof that the device falls within the approved list. The deadline for the submission is the 5th of the month following the provision of aid. The reimbursement should be completed before the 25th of the same month. Grievance redress An appeal can be made to a director of the SAA municipal office handling the case or mechanisms to the SAA Director General. The appeal should be responded to within one month. The decision can further be appealed to the court following the Administrative Processes Code. Monitoring APD oversees delivery and repair. arrangements SAA Inspectorate monitors involved staff of the municipal SAA office. Financing agency SAA Sources of State budget financing 5. Free yearly electronic vignette for road tall Regulated by Roads Act, Art.10 c, Regulation N-19 from 02.12.2008. 360 Paragraph 1 of art. 26 of Persons with Disabilities Act is in force until 01.01.2022, when it should be repealed. The future regulation is not formulated yet. 361 This implies that the person not only must have a need certified by TMEC/NMEC, and completed INA , but that she/he must identify a legitimate (registered) supplier and obtain from it a preliminary invoice and a protocol of its registration (the latter should be available on-line). 217 Regulating agency Road Infrastructure Agency (RIA) Implementing agency SAA, together with RIA Description Permanently disabled people and persons/families raising a child with disabilities (up to 18 years of age, or up to their graduation from high school but not older than 20) have the right to a free yearly road tall vignette for one car. The car can be owned by a person with disabilities or a family. Eligible are also foster parents and relatives raising a child with disabilities. The car should have up to 2000 cm2 engine volume, and up to 117.64 kW power (160 horsepower). The electronic vignette cannot be transferred if the car is sold. Eligibility criteria Type and degree of disability =/>50 percent, certified by TMEC. The car must be property of the person with disability/family property/property of parents or persons raising a child with disabilities. The car must have valid car insurance. Level of benefit Depends on the current price of the yearly vignette for the respective year. Equal to 97 BGN in 2020. Benefit The vignette is bought online, connected to the number of the registered car, delivery/payment through a unified vignette system. frequency Benefit duration and Once a year, valid for 12 months from the date of issue. Renewed by the same renewal requirements procedure as for the issuance. Application and A request is submitted to the responsible municipal SAA office. It should specify decision making personal information, TMEC decision, car registration. In case the request is submitted for the first time, copies of the car passport and the TMEC decision need to be attached too. The request can be submitted in person or by certified post/courier delivery. Grievance redress Not specifically stated in the Roads Act; follows the SAA grievance procedures and mechanisms the Administrative Violations and Sanctions Act. Monitoring arrangements Financing agency Road Infrastructure Agency (RIA) Sources of financing Road Infrastructure Agency (RIA) 6. Social services for children with disabilities Regulated by Social Services Act (SSA)362, Regulation on the Implementation of SSA, Regulation on the Quality of Social Services, Regulation on the Planning of Social Services, Social Assistance Act and Regulation on the Implementation of SAA 362 The Social Services Act was adopted in 2019, but implementation of certain provisions is still in progress (e.g., adoption of the National Map of Social Services: art. 44(1) (Amended, SG No. 71/2020, amended and supplemented, SG No. 14/2021, effective February 2, 2021). Social services are to be financed by the state 218 Regulating agency MLSP, Social Assistance Agency, Agency for Quality of Social Services, State Agency for Child Protection Implementing agency SAA for national planning, preliminary approval of social services, preliminary assessment for some target groups, individual assessment for persons with disabilities, etc. Agency for Quality of Social Services for establishing monitoring criteria, and for monitoring their implementation. Municipalities for planning, provision and control of social services. Private service providers – for provision of social services (privately or through a contract with municipalities). Description Social services for children with disabilities according to the new Social Service Act363 are: Information and consultations: providing opportunities for a child with disability to participate in activities that would enable her/him to learn about and understand problems and challenges she/he faces and to explore and explain possible solutions and actions to overcome them. Therapy: a range of activities for developing, restoring, maintaining, and improving the child’s social, self-care, communication, etc. skills. Rehabilitation: interventions to improve functional abilities of children with disabilities beyond the scope of medical rehabilitation. Skills development: activities to prepare children to acquire skills for independent living and independent management of problems and challenges. Day care: providing care services, individually or in groups, to children with permanent disabilities, for not less than 4 hours a day. Residential care: permanent placement in residential facility. Early disability-centered childhood interventions: Introduced by SSA, it denotes a package of social services provided to children with disabilities and children at risk of development delays under 7 years of age and their families. A package of services includes early identification, early intervention measures, and parenting skills for parents/caregivers. It also includes: (i) information and consultations – same as above; (ii) advocacy; (iii) referral and coordination of services; (iv) respite care and (v) skills development. Social services provided to children with disabilities are still organized as per the Social Assistance Act and related regulation, although the Social Assistance Agency is no longer responsible for their provision and regulation. These services are day care centers for children and/or young adults, day care centers for children and/ or young adults with severe multiple disabilities, day care centers for children and/or young adults with multiple disabilities, center for social rehabilitation and budget according to the standards for financing of social services, determined under art. 45, from January 1 of the year following the adoption of the National Map of Social Services. For now, the funding of social services is provided according to the Social Assistance Act and related bylaws. Similarly, the development of quality standards for social service development and establishment of social services as envisaged by the Law has been delayed. 363 The law is in force, but not all provisions are implemented as the services are yet to be established/reorganized. 219 integration, family type residential care center for children and/or young adults with disabilities.364 Day care center for children and/or young adults365 is a form of support for children, youth, and adults with permanent disabilities, in which conditions are created for services corresponding to their daily and rehabilitation needs, as well as the needs for leisure activities. Beneficiaries are assisted by professionals for the purpose of social inclusion and prevention of their placement in a specialized institution. Day care centers with weekly support also provide residence during the week for those persons who live far away from the service and for whom the daily visit is difficult due to the distance. Day center for children and/or young people with severe multiple disabilities supports children and young people with more than 90 percent of disability or permanently reduced work capacity unable to self-care. In these centers, specialist provide support to persons aiming at social inclusion and prevention of their placement in a specialized institution Center for Social Rehabilitation and Integration366 is a form of hourly support for children or adults, related to rehabilitation, social and psychological consultations, vocational guidance and realization, restoration of skills for leading an independent life, preparation and implementation of an individual programs for social inclusion, including for people with addictions. Family Type Residential Care Center for children and/or young adults367 with disabilities is a residential care facility where care is organized in a manner that emulates a family setting for a limited number of people - not more than 15. The center can be used in combination with other social, health, educational and other services and in accordance with the needs of the residents. Provision of social services is delegated to municipalities. They can provide a broader menu of services than those mandated by laws, but at their own expense. Municipalities develop and provide social services as part of the national planning under the National Social Service Map. The plan regulates maximum capacity per the type of service based on the assessed demographic situation and needs at municipal, district, and national level. Models of social services provision vary, as it is up to municipalities to choose the model that is best suited to their needs. The provision can be contracted out to private service providers following public procurement rules. Eligibility criteria Children with disabilities >50 percent certified by TMEC. Their families/care providers. Completed “preliminary needs assessment”, stipulated under the Social Services Act, prepared by a municipal body, or completed PDA INA prepared by a SAA 364 Art. 36 Regulation of Implementation of Social Assistance Act, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjw7P yskoXxAhV6_7sIHTjkDSEQFjACegQIExAD&url=https%3A%2F%2Fold.mlsp.government.bg%2Fckfinder%2Fuserfi les%2Ffiles%2FPPZSP.pdf&usg=AOvVaw2IiTVfLfgYh_hXLCtQKfJO 365 Paragraph 3, point 21 of Additional Provisions to the Regulation for the Implementation of the Social Assistance Act, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjw7P yskoXxAhV6_7sIHTjkDSEQFjACegQIExAD&url=https%3A%2F%2Fold.mlsp.government.bg%2Fckfinder%2Fuserfi les%2Ffiles%2FPPZSP.pdf&usg=AOvVaw2IiTVfLfgYh_hXLCtQKfJO 366 Ibid. 367 Ibid. 220 municipal office. The need for services must be identified and stated in the assessment report. Services can only be used in the municipality where the current address of the family/parent is registered. It is possible to use services in another municipality, but only if there is an inter-municipal agreement. To place a child with or without disability into residential care, a court decision is needed. The exceptions are residential care placement for up to 30 days per year of children with a degree of disability >50 percent in need of constant medical supervision and care, and a placement of children up to 3 years of age with a degree of disability >50 percent in need of constant medical supervision and support. Level of benefit Based on need, which is determined through the individual assessment on the basis of which an individual intervention plan is developed.. Benefit Based on the intervention plan. delivery/payment frequency Benefit duration and As above. renewal requirements A contract with a service provider is signed for a short-term (up to six months), medium-term (up to one year), and long-term (up to 3 years). It is renewable if it falls within the validity of the needs assessment. Application and Based on the SSA provisions, the process is initiated by a parent/guardian/care decision making giver and includes: Stage 1: Obtaining TMEC decision of >50 percent disability. Stage 2: Requesting services and assessment of needs through one of the following options368: Option 1: The parent requests an individual needs assessment at the municipal SAA office, completes the self-assessment and provides the TMEC decision. Within 30 days he/she receives the assessment conclusion with approved social services. Option 2: The parent requests a service at the municipal office and provides the TMEC decision. Preliminary assessment is conducted within 20 days. The parent receives information about approved services and is directed to a specific type of service. Currently the role of the municipal office is executed by the Social Assistance Agency directorates at the municipal level.369 Stage 3: Accessing services After the decision with prescribed services is received, the family approaches a service provider. Three outcomes are possible: (i) acceptance; (ii) waitlisting and (iii) rejection. 368 The SAA also establishes one more option, yet to be implemented in practice: the parent applies directly to the service provider and the child starts using the service for a period of two months (common standard), after which the parent must request the extension. 369 Paragraph 3 of Final provisions of Regulation on implementation of Social Service Act regulates that the access through a municipal office is in relation to paragraph 44(1) of SSA Final Provisions, https://www.lex.bg/bg/laws/ldoc/2137207105. 221 Grievance redress The “preliminary assessment” and the “individual needs assessment” conclusions mechanisms can be appealed respectively to the mayor of the responsible municipality and the Director of SAA. Additionally, the appeal can be directed to the Administrative Court. An appeal concerning the quality of services can be made to the mayor of the responsible municipality or to the Agency for Quality of Social Services. Monitoring Agency for the Quality of Social Services arrangements Financing agency Ministry of Finance & municipal budgets (for not “delegated”, i.e., extra services.) Sources of financing State and municipal budgets (municipal for extra services) 7. Social services for adults with disabilities Regulated by Social Services Act (SSA), Regulation on the Implementation of SSA, Regulation on the Quality of Social Services, Regulation on Planning of Social Services, Methodology for Determining the Tax Amounts, Social Assistance Act and Regulation on the Implementation of SAA Regulating agency MLSP, Social Assistance Agency, Agency for the Quality of Social Services Implementing agency SAA for national planning, preliminarily approval of social services, preliminary assessment for some target groups, individual needs assessment, etc. Agency for Quality of Social Services for establishing quality standards and monitoring criteria and conducting monitoring and control. Municipalities – for planning, provision, and control of social services. Private service providers – for provision of social services to individuals directly or based on a contract with a municipality. Description SSA stipulates the types of social services for adults with disabilities. They include: (i) information and consulting; (ii) therapy; (iii) rehabilitation; (iv) skills development; (v) day care; and (vi) residential care. As provision of social care services transitions from the Social Assistance Act to the Social Service Act, delivery of social services for adults with disabilities is still organized as per SAA and related regulation. The services are: i) Day and Weekly Care Centers for adults with severe and multiple disabilities, ii) Center for Social Rehabilitation and Integration, iii) Family Type Residential Care for persons with psychiatric disorders/persons with mental retardation/ physical disabilities/ dementia and iv) Sheltered housing and Transitional housing.370 370 Art. 36 of the Regulation for Implementation of the Social Assistance Act, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjw7P yskoXxAhV6_7sIHTjkDSEQFjADegQICRAD&url=https%3A%2F%2Fwww.mlsp.government.bg%2Fuploads%2F41 %2Fravni-vzmozhnosti%2Fpravilnik-za-prilagane-na-zakona-za-socialno-podpomagane- 27112020.rtf&usg=AOvVaw3QVxQUJbnEM4FXgTWBfyKs 222 i) Day and weekly care centers for adults with severe and multiple disabilities371 These centers provide day and weekly care to adults with permanent severe and multiple disabilities assisting them to meet their daily, rehabilitation and leisure needs. The objectives include prevention of social exclusion and of their placement in specialized residential institutions. ii) Centers for Social Rehabilitation and Integration372 Centers for Social Rehabilitation and Integration offer hourly assistance to adults with disabilities and to people with addictions. The hourly assistance includes rehabilitation and social and psychological counseling, career guidance, etc. iii) Family Type Residential Care Centers for Persons with Psychiatric Disorders, Persons with Mental Retardation, Persons with Physical Disabilities and Persons with Dementia373 These centers provide residential care in a family like setting to up to 15 adults. The residents can also use social, health, educational and other services, depending on their abilities and needs. To be placed in these centers, the users must be certified by TMEC/NMEC as having permanently reduced work capacity/disability >71%. iv) Shelter and Transitional Housing374 Sheltered housing for people with mental disorders provides housing to adults with mental disorders with permanently reduced work capacity/disability of over 50%, who, supported by the professionals, live independent life in a family like environment. This service is offered to not more than 8 individuals per house. Sheltered housing for people with mental retardation provides housing to individuals with mental retardation with permanently reduced work capacity/disability of over 50%, who supported by the professionals live independently in a family like environment. This service is offered to not more than 8 individuals per house. Sheltered housing for people with physical disabilities provides housing to individuals with physical disabilities with permanently reduced work capacity/disability of over 50%, who supported by the professionals live independently in a family like environment. This service is offered to not more than 8 individuals per house. Transitional housing provides accommodation to up to 8 adults with disabilities per house, as well as specialists’ assistance for acquiring practical skills for independent life and for supporting their inclusion into community. In addition to social services as defined by SSA, there are specialized institutions which are not counted as residential care, although they still provide long-term residential care for persons with disabilities. These specialized institutions remain from the socialist period. Their provision remains according to the Social Assistance Act where they were defined initially. The new Social Service Act does not consider them as social services for residential care as the way they are organized and structured is in contradiction with the principles of community-based care. 371 Paragraphs 21 and 21a of the Regulation for Implementation of the Social Assistance Act, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjw7P yskoXxAhV6_7sIHTjkDSEQFjADegQICRAD&url=https%3A%2F%2Fwww.mlsp.government.bg%2Fuploads%2F41 %2Fravni-vzmozhnosti%2Fpravilnik-za-prilagane-na-zakona-za-socialno-podpomagane- 27112020.rtf&usg=AOvVaw3QVxQUJbnEM4FXgTWBfyKs 372 Ibid. Paragraph 22. 373 Ibid, Paragraph 26. 374 Ibid. Paragraphs 27 and 32. 223 They are planned to close by 2035.375 They provide the following services: Home for Adults with Mental Retardation is a specialized institution for people with "mental retardation" as determined by an expert decision of TMEC/NMEC, which creates conditions for services that meet their daily, social, and therapeutic needs. Home for Adults with Mental Disorders is a specialized institution for people with primary diagnosis that falls within the scope of mental disorders, established by an expert decision of TMEC/NMEC, in which conditions are created for services corresponding to their daily, social and therapeutic needs. Home for Adults with Physical Disabilities is a specialized institution for persons with physical disabilities, established by an expert decision of TMEC/NMEC, which creates conditions for services that meet their daily, social, and therapeutic needs. Home for Adults with Sensory Disorders is a specialized institution for persons with sensory disorders established by an expert decision of TMEC/NMEC, which creates conditions for service that meet their daily, social, and therapeutic needs. Home for Adults with Dementia is a specialized institution providing a range of social services to people with dementia or Alzheimer's disease, established by a medical protocol from MAC and/or by an expert decision of TMEC/NMEC. Eligibility criteria Adults with TMEC/NMEC certified degree of disability >50 percent. In general, eligibility criteria are the same as in the case of children with disabilities (see above) with few differences: (i) preliminary assessment in the case of adults with disabilities under full or partial guardianship is conducted by the SAA office, not local municipality, because municipality is responsible for the implementation of guardianship measures; (ii) to place a person with disabilities under guardianship into residential care or specialized institutions, a court decision is needed; (iii) residential care placement should be considered only after all other care options have been exhausted. Level of benefit Same as in the case of children with disabilities. However, adults with disabilities are required to pay user fees, which are regulated by the Council of Ministers. The fees have a ceiling calculated as a maximum percentage of the income of the person, depending on the types of social services. Benefit Same as for children with disabilities delivery/payment frequency Benefit duration and Same as for children with disabilities renewal requirements Application and Same as for social services for children with disabilities decision making Grievance redress Same as for social services for children with disabilities mechanisms Monitoring Same as for social services for children with disabilities arrangements 375 Paragraph 33 from the Final provisions of SSA, https://www.lex.bg/bg/laws/ldoc/2137191914. 224 Financing agency Same as for social services for children with disabilities 8. Assistant’s services for persons with disabilities Regulated by Social Services Act, Regulation on the Implementation of the Social Services Act, Regulation on the Quality of Social Services, Employment Promotion Act, National Employment Plan for 2020. Regulating agency MLSP, SAA, Agency on the Quality of Social Services, Employment Agency (EA). Implementing agency SAA, municipalities Description The SSA regulates the services of an assistant provided at home or outside of it for: (i) self-care; (ii) movement and transportation; (iii) change of the body position; (iv) housekeeping and other daily activities; (v) communication (as defined by SSA). The Employment Promotion Act regulates assistants’ services to persons with disabilities as a program for subsidized employment of assistants to persons with disabilities. A program called “National program for assistants for persons with disabilities” provides “personal assistant” and “assistant tutor” to persons with disabilities. Services are provided for up to four hours and include: • Food delivery and preparation and help with eating. • Shopping. • Assistance with personal hygiene: dressing/undressing, washing, bathing, hair combing, getting into a wheelchair, etc. • Housekeeping • Other tasks such as lighting a fire, chopping and carrying wood, shoveling snow, etc. The number of assistants for the year is planned in the “National Employment Plan”. In 2020, the national program “Providing Support at Home” was implemented. It provided housekeeping assistants for persons with disabilities with a degree of disability between 80 percent and 89.99 percent with TMEC assigned support from others, as well as for persons with disabilities of retirement age not able to self-care. Based on the National Employment Plan the assistants’ support is organ ized by state institutions and municipalities. The recruitment of assistants is implemented by local offices of Employment Agency (EA), the applications and provision of the service is organized by municipalities and the verification of eligibility is performed by municipal SAA offices. Eligibility criteria TMEC certified disability of at least 50 percent and its conclusion that a person needs assistance from other people. Persons in retirement age, incapable of self-care do not need a TMEC decision; the practice is that a decision of a medical advisory committee (MAC) is sufficient. MACs for hospital or pre-hospital care are bodies created under the Health Act; they are affiliated with a specific medical institution and are established by an Order of the Regional Health Inspectorate on a yearly basis. They can be general or specialized and should comprise at least two permanent members – medical doctors with a certified specialization. A person can use services of an assistant under one legal act only (to avoid double dipping). 225 A conclusion from “preliminarily assessment” that she/he needs services of an assistant. This assessment is organized by a local authority. The same authority acts as service provider. In addition, to be eligible for assistants’ services under the employment program mentioned above, the following is needed too: (i) the person with disability’s income in the month proceeding the application is lower than 5 times the guaranteed minimum income,376 or up to 375 BGN per family member; (ii) the person cannot be registered as a business-owner; (iii) the person cannot have other sources of income (property, etc.). The eligibility for this program is checked by the municipality as its provider. Level of benefit Under the National Employment Plan, the service is limited to up to 4 hours per day within a calendar year for which the Program is valid. Benefit Services of an assistant regulated under the Employment Promotion Act is up to 4 delivery/payment hours a day. frequency Benefit duration and One (calendar) year. The Program funds the salary of the assistants for up to 12 renewal months during the calendar year. Renewal is required for the next calendar year. requirements Application and Following the procedure under the National Employment Plan: decision making The person, or her/his legal representative, submits a request form to the municipal administration to be included in the program. The municipality forwards the information to the relevant local office of the SAA, which verifies the information and must decide within ten days if the person will be included in the program. After a confirmation that the person fulfills the requirements, the municipal administration prepares an individual needs assessment377 and determines the number of hours of assistant’s services. The municipality keeps a list of requests; in case the demand is higher than capacity to meet it, first come – first served principle applies. In parallel with the applicant assessment, the municipal administration requests from the Employment Office to direct the needed number of job seekers to serve as assistants. The municipality signs short-term contracts with the assistants. Grievance redress Under the Social Services Act – as with all other social services. mechanisms Under the National Programs for Employment – following the Administrative Process Code, it is not specifically mentioned in the program. Monitoring arrangements 376 The guaranteed minimal income is determined by the Council of Ministers; it has been 75 BGN since 2017. 377 Note that this assessment is separate from the individual assessment conducted by SAA, which is used to assess eligibility for personal assistance, monthly allowance in cash and targeted allowances for disability. 226 Financing agency Employment Agency Sources of financing EA budget under the National Employment Plan Budget as part of the National Budget 9. Personal assistance to persons with disabilities Regulated by Personal Assistance Act, Order № RD-07-7 from June 28, 2019, on inclusion in the personal assistance mechanism, Persons with Disabilities Act, Regulation on Implementation of PDA, Methodology for Individual Needs Assessment for support to people with disabilities Regulating agency MLSP Implementing agency SAA, municipal administration Description Personal assistance is regulated as a support mechanism to persons with disabilities for their full and active participation in society, to carry out activities corresponding to their personal, domestic, or social needs, to overcome obstacles to functional limitations, to help them exercise their fundamental rights, and to have opportunities for choice, independent living, and access to services and activities. Only in cases when the choice is not made, a municipality as a provider should find and propose a personal assistant. In most cases, this assistant is a spouse or a close relative of the person with disability.378 The personal assistance mechanism allows parents and relatives who take care of persons with disabilities to receive remuneration for this work under a labor contract. The contract includes social security coverage. The Social Services Act, which came into force in 2019, recognizes assistant services as a social service. The Personal Assistance Act regulates that anyone (employed, unemployed, self- employed), pensioner or a person with a disability may be an assistant. This differs, for instance, from the programs under the National Employment Action Plan (implemented only in 2020) which requires that only persons registered as unemployed can be employed as home assistants. A person requesting personal assistant services need to undergo an individual needs assessment by SAA (PDA INA). For other assistants’ programs, an assessment is also conducted, but the assessment tools and methods vary by municipality or service provider (see above). The level of personal assistance depends on the INA assessed level of dependance – it ranges from several times a month to 8 hours daily. Eligibility criteria Eligible to receive services of the personal assistant are persons with a permanent disability of >90% and in need of assistance and care by others, as established by TMEC/NMEC; and children/young persons with type and degree of disability (for young persons) >90% and without specific assistance by others as established by TMEC/NMEC. 378 The motivation for this law was to provide a mechanism through which, spouses, children and other informal care and support givers to persons with disabilities will be compensated. 227 Completed individual needs assessment. While the assessment per se does not determine the right to personal assistance, as that right depends on the TMEC/NMEC conclusion about the need for assistance by others, it is used to determine hours of support the applicant would receive. The individual needs assessment is based on a self-assessment questionnaire about limitation in functioning in performing daily activities a person with disability experiences, as well as on an assessment instrument filled out by a social worker responsible for the case. The INA conclusions should include a statement about whether the person needs the assistance and in which of the four levels of benefit he/she falls. The assessment is conducted by a local SAA office. Once the level of personal assistance support is determined, the person with disability contacts the local administration, submits the issued “direction for personal assistance” and provides the name of the personal assistant. The municipality signs a contract with the personal assistant who then starts receiving a salary for her/his services. Level of benefit There are four levels of this benefit: For the first degree of dependence – up to 15 hours per month, For the second degree of dependence – up to 42 hours per month, For the third degree of dependence – up to 84 hours per month, For the fourth degree of dependence – up to 168 hours per month. Persons with disabilities who are awarded this benefit have some of their other benefits in cash reduced: (i) for children whose families receive a family allowance for children with disability, by up to 380 BGN. The exact deduction depends on the allocated number of hours of support; (ii) for adults receiving pension and a supplement for assistance from others, the amount of the supplement is deducted. Benefit Monthly, upon submission of a monthly report by assistant, signed by a person with delivery/payment disability, to the municipality. frequency Benefit duration and Personal assistance is awarded for the validity of the TMEC/NMEC decision on renewal disability, which is usually 3 to 5 years. For persons for whom the TMEC decision is requirements valid for life, the renewal period is 5 years. The renewal procedure is the same as for the original application. During the renewal, there may be a gap in the service provision. Application and The person submits to the local SAA office a request for INA, completed self- decision making evaluation form, the TMEC/NMEC decision, and her/his ID document. The request must be reviewed within 20 days and a home visit is conducted. The aim of the home visit is for the social worker to meet the person and get a better understanding of his/her situation. The process is completed with the issuance of the individual assessment report together with a “direction” for the use of personal assistance service, including the number of its hours. After having received INA and the direction, the person submits a request to receive personal assistance to the municipality as service provider, according to her/his current address. In the request, the name of the person she/he has chosen to be his/her personal assistant should be indicated, as well as the name of an alternative personal assistant. If he/she cannot indicate a specific person, the municipality suggests a personal assistant. 228 The chosen personal assistant submits documents required for the appointment and formally starts the position after signing the contract. Grievance redress Appeal/ complaint is possible at all stages following internal grievance mechanism mechanisms of the SAA and a municipality, and following the Administrative Process Code. If person is not satisfied with the service provided, she/he can refuse to sign the service report and take the matter with the municipality. Monitoring MLSP monitors the Personal Assistance Act implementation, the municipality arrangements supervises provision and quality of personal assistance services, SAA monitors the entire process. Financing agency SAA, NSSI Sources of financing The State Budget: municipalities receive funds through the Social Assistance Agency. National Social Security Institute: funds saved through deduction from support by others allowance on the account of personal assistance (see the level of benefits above) are transferred to the provider municipality. Social Assistance Agency: funds saved through deduction from the allowance for a child with a disability on the account of personal assistance (see the level of benefits above) are transferred to the provider municipality. 10. Measures to support employment of persons with disabilities (I) Regulated by The Employment Promotion Act (EPA), Regulation on the Implementation of the EPA, National Employment Action Plan for the respective year, The Persons with Disabilities Act, Regulation on the Implementation of the Persons with Disabilities Act. Regulating agency MLSP, EA, PDA Implementing agency EA, PDA Description Measures include subsidized employment of persons with disabilities and measures to support their entrepreneurship. Subsidized employment measures are planned annually in the National Employment Action Plan and are implemented by EA and its territorial branches. They include: National employment and education program for persons with permanent disabilities. This program provides a wage subsidy for 24 months to employers who offer employment to persons with disabilities registered with the EA as unemployed. Encouraging employers to hire unemployed persons below 29 years of age with permanent disabilities, as well as from other vulnerable groups. This program provides a wage subsidy for up to 9 months to employers who employ persons who meet the criteria. The 2020 NEP envisaged only 5 persons to benefit from this program. 229 Encouraging employers to hire unemployed persons with permanent disabilities. A partial subsidy (for wages and social security contributions) to employers who hire persons with disabilities. Encouraging employers to hire unemployed persons with permanent disabilities under full- or part-time contract. Same as previous. The difference from the previous measure is that it allows for the possibility to hire on hourly basis. Disabled persons’ entrepreneurship is provided for in PDA as a program to support independent economic activity of persons with disabilities through financing project for commercial initiatives. It is regulated and implemented by APD. National program for employment of persons with disabilities 379 focuses on providing access to existing or newly created jobs for people with permanent disabilities, adaptation of existing jobs, equipping new workplaces for people with permanent disabilities corresponding to the nature of their disability, qualification and re-qualification, training for professional development. It is implemented by APD. Eligibility criteria TMEC disability certificate. For programs under EA, a person must register with local EA office as unemployed. For independent economic activity under APD, it is required that the TMEC decision does not prohibit the person from performing the activity for which she/he is applying. Level of benefit Differs by program. National employment and education program for persons with permanent disabilities: This program provides a wage subsidy for 24 months to employers who offer employment to persons with disabilities registered with the EA as unemployed. The subsidy is equal to a minimum wage per month (610 BGN in 2020; 650 for persons with disabilities with a higher education degree) plus social security contributions paid by the employer. Hourly work under a part-time contract is possible with a set remuneration per hour. Encouraging employers to hire unemployed persons with permanent disabilities below 29 years of age, as well as from other vulnerable groups : up to 500 BGN for persons with disabilities, and 550 BGN for persons with disabilities with a higher education degree. The support is offered for up to 9 months. Encouraging employers to hire unemployed persons with permanent disabilities : it covers 50 percent of the minimum wage plus social and healthcare insurance payments for a period from 3 to 12 months. Encouraging employers to hire unemployed persons with permanent disabilities on full-time or part-time contract: 75 percent of the minimum wage plus social and healthcare insurance security payments for a period of up to 6 months. Projects for independent economic activity: up to 20 000 BGN grant per project. National program for employment of persons with disabilities annual budget is over 2 million euro. 379 Set by the Persons with Disabilities Act, Article 44, https://www.lex.bg/bg/laws/ldoc/2137189213, National program for employment of persons with disabilities: https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.mlsp.government.bg%2Fuploads% 2F38%2Fkhu%2F1-nacionalna-programa.docx&wdOrigin=BROWSELINK 230 Benefit A person with disability can benefit from one of the programs within one calendar delivery/payment year. frequency Benefit duration and Depends on the program (see above). renewal requirements Application and A person with disability after having registered with the local EA office is put in touch decision making with an employer. An application to register can be submitted in person, by mail or electronically with an electronic signature. The applicant should also attach a copy of ID and the TMEC/NMEC decision. Grievance redress Following the procedure of the Administrative Processes Code. mechanisms Monitoring n/a arrangements Financing agency EA under MLSP Sources of financing EA budget within the State Budget 11. Measures for employment of persons with disability (II) Regulated by The Persons with Disabilities Act, Regulation on the Implementation of the Persons with Disabilities Act, The Employment Promotion Act, Regulation on the Implementation of the Employment Promotion Act Regulating agency MLSP, The Chief Labor Inspectorate Implementing agency APD, EA Description Employment quotas: All employers with more than 50 employees are required to employ persons with disabilities. For employers with 50 to 99 employees, one person with permanent disabilities. For employers with 100 or more employees – 2 out of each 100 of staff. Employers not complying are fined. Support for finding employment for unemployed persons with permanent disabilities or other vulnerable groups: This is a mediation service that offers support to persons with disabilities in the process of applying for a job. It is free of charge and is provided by the employees of EA and by private employment mediators. This service also includes support for at least first 12 months of employment. EA pays 700 BGN to private mediators for each reported labor contract with a person with disabilities. Specialized enterprises and cooperatives of persons with disabilities : These are entities established with special status for ensuring specialized labor conditions for persons with disabilities. To receive a specialized enterprise status, an enterprise must employ persons with =/>50 percent of disability; the exact proportion depends on the type of disability: • For specialized enterprises and cooperatives of persons who are blind or with visual impairments and for persons with intellectual disabilities or mental disorders – minimum 20 percent of employees, 231 • For specialized enterprises and cooperatives of persons with hearing impairments and for persons with other impairments – minimum 30 percent of employees. Privileges of specialized entities are: (i) reimbursement of half of the paid social insurance contributions on the account of employees. This is done monthly after a report by the entity of the paid social insurance contributions. The entity is obliged to invest the reimbursed amount in activities to support rehabilitation and social inclusion of the persons with permanent disabilities and the staff supporting them; (ii) participation in special programs organized yearly by APD. Centers for sheltered/protected employment: These centers should offer support for work integration of persons with multiple disabilities, psychiatric disorders and/or intellectual disabilities. Those centers are a new measure (introduced in 2020) and so far, only one has been established. Eligibility criteria TMEC certified disability of >50 percent. For Centers for sheltered employment, multiple disabilities are required - a person should have at least two impairments, both at >50 percent. 12. Tax reductions for persons with disabilities and for parents of children with disabilities Regulated by Taxation of Individuals’ Income Act Regulating agency Ministry of Finance, National Revenue Agency Implementing agency National Revenue Agency Description Tax reductions are applied to persons with disabilities income as individuals. Tax reductions for parents of children with disabilities are applicable to all types of income. Parents receive tax reduction depending on the number of children. Eligibility criteria Applicable to all persons with disabilities regardless of the type of income, as long as they have a TMEC/NMEC decision on disability of >50%. Tax reduction for parents is applicable when the family member declares a child (up to 18 years of age) with >50% disability in the annual tax declaration. Only one parent can claim the tax reduction. Benefit level Total of individual income tax reduction is limited to 7,920 BGN per year (determined annually). The tax reduction for children with disabilities is also determined annually. The amount is currently 2,000 BGN380 per child with disability and it is deducted from the total annual taxable base. 380 For comparison, tax deduction for one child without disability is 200 BGN, for two 400 BGN, and for three or more 600 BGN. 232 Benefit delivery/ The tax reduction for persons with disabilities is applied: (i) after the submission of payment frequency the annual tax declaration to the tax authorities; (ii) when the person is employed with a labor or civic contract and her/his disability is declared to the employer (TMEC/NMEC decision), the employer does not withhold income tax up to the ceiling of 7,920 BGN. The tax reduction for children with disabilities is applied: (i) after the annual submission of the tax declaration to the tax authorities as a cashback by NRA; (ii) in the form of deduction by the employer in the last month of the calendar year in case the parent has a labor contract. Benefit duration and Both tax reductions can be used for the year in which disability has occurred, as well renewal as for the year when the validity of TMEC/NMEC certificate expires. requirements For elderly people with disabilities, the tax reduction is not limited to the duration of the TMEC decision, but it is given for life. Application and Application is with the tax declaration; no copies of TMEC/NMEC decisions are decision-making required. It is part of the annual income tax declaration; or is acknowledged as part of the labor contract obligations of the employer. Grievance redress Internal grievance: an appeal can be submitted to the Director of the responsible mechanisms territorial directorate of NRA. Court appeal: to the relevant administrative court, following the Code of Administrative Procedure. Financing agency NRA Sources of financing State budget 13. Other benefits Regulated by Tariff № 4 of the Ministry of Interior for fees collected within its system based on the State Taxes Act, the Social Protection Act, the Regulation on the Implementation of the Social Protection Act, the Regulation of MLSP № RD-07-5 from May 16, 2008, on the targeted support for heating, The Health Insurance Act, decisions of the Council of Ministers, The Higher Education Act. Regulating agency Ministry of Interior, SAA, National Health Insurance Implementing agency Various government bodies Description Persons with disabilities are entitled to a discount when applying for identity documents (ID card, passport and driving license). Exempt from fee payment/co-pay for medical examination by general practitioner and hospital treatment Two free rail journeys per year inside the country; this also applies to the accompanying person, when such is required, to personal assistants and guide dogs. Social Assistance Benefit. Every individual and family in temporary or lasting hardship may apply for this program at the SAA local office. Based on Article 9 of the SAA regulation, persons or families, whose income for the previous month is lower than a certain differentiated minimum income threshold is eligible for the monthly cash support. The basis for determining the differentiated minimum 233 income is the guaranteed minimum income (GMI), whose monthly amount is determined by the Council of Minister. The differentiated minimum for persons with disabilities is determined in the flowing way: • for a person with permanently reduced work capacity >50 percent - 100 per cent of the GMI 381 • for a person with permanently reduced work capacity >70 percent - 125 per cent of the GMI. Eligibility requirements382 such as movable/immovable property and employment status applicable to general population are not applicable to persons with disabilities. In addition, persons with disabilities are exempted from participating in community work. Targeted heating allowance.383 Entitled to targeted heating assistance are persons and families whose average monthly income for the previous 6 months before the month of submission of the application-declaration is lower or equal to the differentiated income for heating and who meet conditions under Art. 10 and 11 of the Regulations for implementation of the Social Assistance Act. The differentiated income for heating is different for different groups: - for a person with permanently reduced work capacity >50% - 1.20 of the basic income for heating (BIH) approved yearly by the Minister of Labor and Social Policy, - for a person with permanently reduced work capacity >70% - 1.42 of the BIH, - for a person with permanently reduced work capacity >90% - 1.72 of BIH. Students with disabilities. Students, doctoral students and postgraduates with sensory disabilities and others with permanent disabilities and reduced work capacity >70% are entitled to special benefits provided for in the regulation on higher education.384 Health insurance is covered by the state for veterans and war victims who do not have health insurance, persons with disabilities, persons who receive a disability pension as well as parents, adoptive parents, spouses or one of the parents of the mother or father who takes care of a disabled person with a disability over 90% in need of assistance for daily routine.385 Persons with disabilities are entitled to discounted admission to museums and galleries386. Persons with disabilities have certain benefits at the work place. These benefits pertain to employment contracts and are to be implemented by the employer under the Labor Code387 obligation. 381 Guaranteed Minimum Income: https://www.mlsp.government.bg/uploads/1/zakoni/pms-305-20171.pdf. 382 To qualify for social assistance, general population needs to meet several eligibility criteria related to income, size of dwelling, property ownership, registration with the Employment Agency at least 6 months before the submission of the application-declaration for social assistance and not to have rejected offered jobs or education/training, etc. 383 Аrt. 10 of the Regulation on the Implementation of the Social Protection Act, https://www.lex.bg/laws/ldoc/- 13038592; Regulation of MLSP № RD-07-5 from 16.05.2008 for the conditions and order for awarding the targeted support for heating; https://www.lex.bg/laws/ldoc/2135588875. 384 Art. 70, paragraph 2 of the Higher Education Act. 385 Art 40, paragraph 2 of the Health Insurance Act; https://www.nssi.bg/images/bg/legislation/laws/ZZO.pdf. 386 Art. 187 of the Cultural Heritage Act, https://www.lex.bg/laws/ldoc/2135623662. 387 The Labor Code, https://www.noi.bg/images/bg/legislation/Codes/KT.pdf. 234 - Persons with disabilities (>50%) with labor contracts have the right of additional paid leave days compared to other employees at the same position388. - Protection from dismissal of working persons with disabilities. An approval of dismissal from the National Labor Inspection389 is required. Persons with disabilities are entitled to several benefits at the municipal level. Those are applicable in municipalities by local decisions of the municipal council and municipal administration, and they include: - right to a free of charge parking and guaranteed access to parking places, - reduced price for the use of public transport, - additional points when applying for public municipal housing, - guaranteed access to a kindergarten for children with disabilities. Furthermore, within their authority, municipalities ensure accessible built environment in kindergartens and schools, accessible public transport by adapting the existing public transport and commissioning vehicles technically adapted for use by persons with disabilities, special transport services for people with disabilities. Eligibility criteria TMEC/NMEC certified disability of >50 percent. Benefit Level Varies per benefit. 388 The Labor Code Art. 333, par. 2. 389 Ibid. 235 Annex 5: Persons with Disabilities Act - Individual Needs Assessment templates (informal translation from Bulgarian into English)390 Individual Needs Assessment Report for People with Disabilities Related to Application No ......................................./..................................20....................... Component I: Details about the person with a disability Personal details (First name, patronym, and family name; current address; age; gender; social status) Self-assessment of the difficulties in/outside home environment Other information Component II: Objective findings on the functional difficulties and barriers to a person with a disability in everyday life and other activities Degree of the permanent loss of the ability to work or type and degree of disability, as well as health condition at the time of the assessment (A certificate issued by MAC, TMEC or NMEC) Type of difficulty in functioning Degree of difficulty in functioning Degree of inclusion in the social environment Mobility in the social environment and difficulties outside home Need for the provision of a specific type of support Other existing functional difficulties and barriers in everyday life and other activities as established based on the self-assessment of the person with a disability and the findings in the course of the assessment Component III: Conclusions with specific supportive measures 1. 2. 3. 4. ……………………………………. (Component III is filled in based on the findings from Component II) 390 Annex 1 to the Methodology for conducting the individual needs assessment of people with disabilities, Lex.bg - Laws, Regulations, Constitution, Codes, State Gazette, Implementing Rules 236 Date: Validity: Responsible social worker who has prepared Component I and Component II: ……………………………………………………. (First name and family name/signature) Component III prepared by: ……………………………………………………. (First name and family name/signature of the social worker) ……………………………………………………. (First name and family name/signature) ……………………………………………………. (First name and family name/signature) Note: Individual needs assessment is communicated to the applicant in writing, together with the orders and directions (referrals). The information in Components I and II is filled in by the responsible (“case assigned”) social worker. The information in Component III is filled in by the specialized department of the Social Assistance Directorate. Form to be filled in by the responsible social worker391 Individual Needs Assessment Relating to Application No .........................../..........................20............... Date on which the form was filled in Name of the responsible social worker Part 1: Information on the person with disability First name, patronymic and family name Date of birth Current address (City/town, municipality, region, street, number, floor, apartment) Telephone number E-mail address 391 Annex 2 to the Methodology for conducting the individual needs assessment of people with disabilities. Ibid. 237 Does he/she use (a) social service(s) and/or personal assistance? Yes No Please specify: Does she/he receive any type of support as of the assessment date? Yes No Please specify: First name and family name of a legal representative under Article 21(2)(2) through (4) of the People with Disabilities Act Contact details: address, telephone number, e-mail address Family and friends (family, relatives, friends, other trusted persons) 1. 2. Contact details of the family members or friends: address, telephone number, e-mail address 1. 2. General practitioner/physician in charge of the treatment – contact details: first name and family name, telephone number Part 2: Medical expert findings Fill in this part based on official documents issued by medical experts NMEC/TMEC/MAC: Yes – type, Number and date of the document: No Other medical documents: Yes – type, Number and date of the document: (fill in, if needed) No Degree of disability: permanent loss of the ability to work/type and degree of disability, including the need for assistance by another person 238 Part 3: Information on functional insufficiency/health condition of the person with disability Fill in this part with information on the type and degree of disability in each section, regardless of which characteristic is dominant in his/her condition. If the person with disability does not have the relevant problem, reply NO, and do not fill in the section further. 3.1. Intellectual insufficiency Intellectual insufficiency YES NO Opinion of the medical specialist, if needed: Medical specialist who has submitted the expert opinion: name, specialty and contact details 3.2. Physical insufficiency Physical insufficiency YES NO Opinion of the medical specialist, if needed: Medical specialist who has submitted the expert opinion: name, specialty and contact details 3.3. Mental insufficiency Mental insufficiency (including YES NO dementia, autism spectrum disorders and behavioral or personality disorders and others) Opinion of the medical specialist, if needed: Medical specialist who has submitted the expert opinion: name, specialty and contact details 3.4. Sensory insufficiency Sensory insufficiency (sight, hearing, etc.) YES NO Opinion of the medical specialist, if needed: Medical specialist who has submitted the expert opinion: name, specialty and contact details 239 3.5. Other established diseases Other diseases YES NO Please specify: Opinion of the medical specialist, if needed: Medical specialist(s) who has/have submitted the expert opinion: name, specialty Part 4: Information on the existing problems with the functioning of the person with a disability 1 - Fill in Part 4 only if personal assistance has been applied for Fill in this part with information on the problems of the person with a disability in four areas: motor functioning, self-care, orientation and self-protection, and psycho-social functions. It is assumed that there is an existing problem and that the person with a disability experiences substantial difficulties because of the relevant functional constraint. Please specify the degree to which the person with disability is dependent on care in accordance with the scale given for each question. Degrees of dependence/difficulties applicable to Parts 4 and 5. 2 - Degrees 1, 2, 3 are determined in accordance with the difficulties established based on the specific questions under the relevant main question. Degree 4 is determined where overall dependence/difficulty is established regarding the relevant main question. The following scale is used to define a problem of the person with a disability and the need for support in all relevant sections below: 4 = existing problem: degree of total dependence/difficulties 3 = existing problem: degree of very severe dependence/difficulties 2 = existing problem: degree of severe dependence/difficulties 1 = existing problem: degree of moderate dependence/difficulties 0 = no problem/no need for support 4.1. Motor functioning 4.1. Problems Problems: related to motor 4.1.1. The person uses his/her hands consciously and on 0 1 2 3 4 functioning his/her own by taking and moving cups or glasses, opening, and closing doors, and turning water taps on Specify on each item and off. whether a problem is established and what 4.1.2. The person makes fine movements with the hands 0 1 2 3 4 degree of consciously and on his/her own, such as cutting with dependence/difficulty scissors, buttoning, and unbuttoning, and using a pencil is (1, 2, 3, 4), appropriately. depending on the age 240 and the age-related 4.1.3. The person uses his/her feet and legs consciously 0 1 2 3 4 conditions and skills. and on his/her own by walking, crouching, and standing. 4.1.4. The person changes the position of his/her body 0 1 2 3 4 Tick “0” if no consciously and on his/her own by turning in the bed, problem exists. sitting up from a lying position, and standing up from a sitting position. 4.1.5. The person coordinates the movements of his/her 0 1 2 3 4 body consciously and on his/her own and can touch parts of his/her body, stoop, and make concerted movements. 4.1.6. The person moves around his/her home 0 1 2 3 4 consciously and on his/her own, getting up from the bed, moving around the room and the whole house. 4.1.7. The person walks short distances consciously and 0 1 2 3 4 on his/her own, such as walks of 50, 250 and 500 meters. 4.1.8. The person uses stairs consciously and on his/her 0 1 2 3 4 own and can climb up and down the sidewalk, use a vehicle and climb one floor up. 4.1.9. The person overcomes obstacles, such as bumpy 0 1 2 3 4 paths, slopes, or other barriers, outside his/her home consciously and on his/her own. Total score Total score: (Sum total of lines 4.1.1. ‐ 4.1.9.) 4.2. Self-care 4.2. Problems related Problems: to self-care 4.2.1. The person washes parts of his/her body or 0 1 2 3 4 performs other personal hygiene activities, such as washing hands, brushing teeth, or washing other parts of Specify on each item the body, consciously and on his/her own. whether a problem is established and what 4.2.2. The person takes a bath on his/her own, washing 0 1 2 3 4 the degree of the hair, bathing the whole body, and drying after the dependence/difficulty bath. is (1, 2, 3, 4), depending on the age 4.2.3. The person goes to the appropriate facility on 0 1 2 3 4 and the age-related his/her own and uses the toilet, managing the clothes, conditions and skills. sitting, and then cleaning himself/herself. 4.2.4. The person eats and drinks from a cup/glass on 0 1 2 3 4 Tick “0” if no his/her own, recognizing food, using cutlery, and serving problem exists. his/her food. 4.2.5. The person dresses and undresses on his/her own, 0 1 2 3 4 reaching, recognizing, and using clothes and footwear appropriately. 241 4.2.6. The person goes to bed and gets up on his/her 0 1 2 3 4 own, lifting the bedspread, going to bed, tucking, moving the blanket away and getting up. 4.2.7. The person takes care of his/her heath condition 0 1 2 3 4 on his/her own, recognizing, dosing, and taking medicines at the prescribed intervals and in the prescribed dose or using medical devices (injections, oxygen, etc.) on his/her own. (The question is not applicable to persons with disabilities below the age of 18 years) Total score Total score: (Sum total of lines 4.2.1. ‐ 4.2.7.) 4.3. Orientation and self-protection 4.3. Are the Problems: orientation and self-protection of 4.3.1. The person gets his/her bearings on his/her own 0 1 2 3 4 the person with a about himself/herself, time, location, and space, disability recognizing day, night, month, year, city/town and impaired? location regarding streets, buildings and people. Specify on each item 4.3.2. The person can ask for help on his/her own and 0 1 2 3 4 whether a problem is communicate problems verbally or via an alternative established and what channel of communication (body language, symbols) or the degree of other means. dependence/difficulty is (1, 2, 3, 4), 4.3.3. The person can avoid risk situations, such as 0 1 2 3 4 depending on the age crossing the street or self-protection in the use of and the age-related utensils or detergents, at home and outside his/her home conditions and skills. consciously and on his/her own. Tick “0” if no 4.3.4. The person has independent access and security at 0 1 2 3 4 problem exists. home, locking and unlocking doors, opening, and closing windows and not opening the door to strangers. 4.3.5. The person needs special protection measures as 0 1 2 3 4 he/she exhibits risky behavior, fainting or aggression/auto-aggression. Total score Total score: (Sum total of lines 4.3.1. ‐ 4.3.5.) 242 4.4. Psycho-social functions 4.4. Does the Problems: person with a disability 4.4.1. Concentration and sustained attention for 5 0 1 2 3 4 experience minutes, 20 minutes, 45 minutes. problem with the psycho-social 4.4.2. Observance of social behavior rules, 0 1 2 3 4 functions? understanding, accepting, and observing social rules or instructions on how to behave outside the Specify on each line home, in a familiar home environment or an unfamiliar whether a problem is closed environment (kindergarten, school, social services, established and what public buildings, workplace, etc.). the degree of dependence/difficulty 4.4.3. The person organizes his/her daily life consciously 0 1 2 3 4 is (1, 2, 3, 4), and on his/her own, coping with routine situations or depending on the age problems at home, in a closed environment outside the and the age-related home, at meetings and in social contacts conditions and skills. Tick “0” if no problem exists. Total score (Sum total of Total score: lines 4.4.1. ‐ 4.4.3.) Part 5: Information on the impact of constraints on the life of the person with a disability 3 - Fill in Part 5 only if the personal assistance has been applied for. Fill in this part with information on the impact of constraints on the life of the person with a disability in three areas: social functioning, activities in the home environment and social relationships. Please specify the degree to which the person with disability is dependent on care in accordance with the scale given for each question. 5.1. Social functioning 5.1. Problems Problems: related to social functioning 5.1.1. The person uses transport on his/her own, getting 0 1 2 3 4 on and off a vehicle, travelling and choosing an Specify on each item appropriate vehicle. whether a problem is (The question is not applicable to persons with established and what disabilities below the age of 12 years.) the degree of dependence/difficulty 5.1.2. The person manages his/her budget on his/her 0 1 2 3 4 is (1, 2, 3, 4), own by shopping in accordance with the needs, paying depending on the age utility bills and other costs and managing within the and the age-related available funds. conditions and skills. (The question is not applicable to persons with disabilities below the age of 12 years.) Tick “0” if no 5.1.3. The person does shop consciously and on his/her 0 1 2 3 4 problem exists. own and can make a choice, pay for the goods and reach and visit the relevant store or market. 243 (The question is not applicable to persons with disabilities below the age of 12 years.) 5.1.4. The person uses public services on his/her own, 0 1 2 3 4 making choices and reaching and using the service on the spot. (The question is not applicable to persons with disabilities below the age of 18 years.) 5.1.5. The person communicates consciously and on 0 1 2 3 4 his/her own, receiving information through the generally accessible forms of communication. 5.1.6. The person communicates consciously and on 0 1 2 3 4 his/her own, reproducing information through the generally accessible forms of communication. Total score Total score: (Sum total of lines 5.1.1. ‐ 5.1.6.) 5.2. Performing activities in the home environment 5.2. Problems of Problems: the person with a disability in 5.2.1. The person prepares food on his/her own, such as 0 1 2 3 4 performing making a sandwich, mixing products for a single dish or activities in the cooking, including meals for other people. home environment (The question is not applicable to persons with disabilities below the age of 12 years.) Specify on each line 5.2.2. The person manages daily hygiene at home, 0 1 2 3 4 whether a problem is including the maintenance of clothes, cleaning and established and what tidying up. the degree of dependence/difficulty (The question is not applicable to persons with is (1, 2, 3, 4), disabilities below the age of 12 years.) depending on the age and the age-related conditions and skills. Tick “0” if no problem exists. Total score Total score: (Sum total of lines 5.2.1. ‐ 5.2.2.) 5.3. Social relationships 5.3. Problems Problems: of the person 5.3.1. Establish and maintain contacts with other 0 1 2 3 4 with a people on his/her own in the home environment, in a disability in familiar closed environment or an unfamiliar closed social environment outside the home. relationships 244 5.3.2. Participate on his/her own in activities together 0 1 2 3 4 Specify on each item with other people, initiate participation, take interest in whether a problem is participating, and have the opportunity to participate. established and what the degree of dependence/difficulty is (1, 2, 3, 4), depending on the age and the age-related conditions and skills. Tick “0” if no problem exists. Total score Total score: (Sum total of lines 5.3.1. – 5.3.2.) Part 6: Participation in education or the labor market Fill in this part with information on the problems of the person with disability in the educational or labor integration. Specify the current involvement in education or work. 6.1. Involvement in education 6.1.1. What educational 1. Creche institution is the person with 2. Kindergarten a disability trained at/attends currently? 3. School 4. Special school 5. Centre for special educational support 6. Other. Please specify: 7. Not involved in training. Please specify the reasons: 6.1.2. What educational level 1. Pre-school education is the person with a disability trained in currently? 2. Primary education - Elementary – grades I-IV - Junior high (middle) school - grades V-VII 3. Secondary education - Lower secondary school (special profile/vocational class) - grades VIII-X - Upper secondary school (special profile/vocational class) - grades XI-XII 4. Other: 6.1.3. What form of training is 1. Full-time the person with disability 2. Evening classes currently attending? 3. Extramural 4. Individual 5. Independent 245 6. Remote 7. Hybrid 8. Learning on the job (dual education system) What kind of support is the person with disability applying for? 6.2. Participation in the labor market (for people with disabilities in the active working age bracket) 6.2.1. Is the person with a Yes No disability working currently? Yes, a full-time job Yes, a part-time job Yes, a liberal profession Yes, a supported job Yes, a job at a specialized enterprise Yes, a job at a social enterprise Yes, a job at a Protected Employment Centre Yes, other 6.2.2. Is the person with Yes No disability looking for a job? Please specify: …………………………………………………… 6.2.3. What kind of support is the person with disability applying for? Part 7: People surrounding the person with a disability and need for social services/personal assistance Fill in this part with information on the support which the person with disability receives from family members and relatives, professional care and the need for personal assistance. “Support” means the care provided to the person with disability in addition to the usual care. 7.1. Support in a family environment 7.1.1. Can the person with a disability rely on the support Yes No of other persons – family/household members and/or others? If yes, on whom? 1. Partner/spouse 2. Relatives 3. Friends, acquaintances 4. Others, namely: Describe the support provided currently ………………………………………………….. 246 7.2. Support through professional care 7.2.1. Need for professional care Yes No If yes, what type of support? 1 Social services 2 Another type of specialist, namely: 3 Other: Describe the support: ………………………………………………….. 7.3. Need for personal assistance 4 - Fill in when personal assistance is applied for. 7.3.1. Does the person with a Yes No disability need personal If yes, please specify: assistance? The total score is the sum of total Total score: scores from 4.1, 4.2, 4.3, 4.4, 5.1, 5.2 and 5.3 7.3.2. How many hours of personal assistance does the Total hours (monthly): person with disability need? (In words) ……………………………………… The degree of dependence/difficulty for the person with disability is established in accordance with the total score, whereas the number of hours of personal assistance provided to the person with disability is established pursuant to Article 10(2) of the Methodology for Individual Assessment of the Need for Support of People with Disabilities For people with disabilities aged above 18 years, the total score is multiplied 1.235. For people with disabilities in the age bracket of 12 to 18 years, the total score is multiplied by 1.313. For people with disabilities below the age of 12, the total score is multiplied by rate 1.556. 247 Part 8: Targeted aid 8.1. Need for adaptation of the home Fill in this part with information on the housing conditions of the person with a disability. 8.1.1. Are the current living Yes Clarifications: ………………. conditions of the person with disability appropriate? No 8.1.2. Does the average Yes The average monthly income per family member for the last monthly income per member 12 months is in the amount of: of the family of the person with disability meet the No eligibility requirements for financing the adaptation of the home under the People with Poverty line: Disabilities Act? 8.1.3. Has the person with Yes If yes, when disability received targeted aid for adaptation of the home for the last 10 years? No Yes Clarifications: 8.1.4. Is adaptation of the home needed? No 8.2. Need for use of municipal housing Fill in this section with information on the existence of conditions for the provision of targeted aid for the person with a disability to rent municipal housing. 8.2.1. Does the person with a Yes If Yes: disability have a contract for accommodation in municipal housing? No Who has signed the contract (first name and family name): Relationship with the person with disability: - parent of a child with a disability - legal representative of a person with permanent disability placed under full legal incapacity. 8.2.2. What is the status of the 1. Person living on his/her own, person with disability 2. Child with permanent disability, 3. Person placed under full legal incapacity, 4. Other: 8.2.3. Additional information (if needed) 248 8.3. Need for provision of auxiliary aids and tools, equipment and medical devices (AATEMD) Fill in this section with information on the existence of conditions for providing targeted AATEMD to the person with a disability 8.3.1. Does the person with Yes If yes, what type? disability use AATEMD? No 8.3.2. Is the need for using Yes If yes, what type(s) AATEMD established in a medical expert opinion? No 8.2.3. Additional information (If needed) 8.4. Need for purchase of a private motor vehicle (PMV) Fill in this section with information on the existence of conditions for providing financial aid for the purchase of a private motor vehicle (PMV). 8.4.1. Does the person with Yes Clarifications: disability own a PMV at present? No 8.4.2. Are there established Yes mobility difficulties? No 8.4.3. Does the use of a PMV Yes Please specify in what way: help the social integration and No independent life of the person with a disability? 8.4.4. What is the status of the 1. Working person with a disability 2. Student 3. Other Please specify: 8.4.5. Does the average Yes The average monthly income per family member for the last monthly income per member 12 months is in the amount of: of the family of the person with disability meet the No eligibility requirements for financing the purchase of a PMV under the Persons with Poverty line: Disabilities Act? 8.4.6. Has the person with Yes If yes, when disability received targeted aid for the purchase of a PMV for the last 5 years? No 8.4.7. Additional clarifications (if needed) 249 8.5. Need for the use of balneological treatment and/or rehabilitation services Fill in this section with information on the need for providing the person with a disability with balneological treatment and/or rehabilitation services. The need is assessed on the basis of the degree of the permanent loss of the ability to work or the type and degree of disability of the person with disability 8.5.1. Does the person with Yes Clarifications: disability need to use balneological treatment and/or rehabilitation services? No 8.5.2. Does the person with Yes Clarifications: disability need escort to use balneological treatment and/or rehabilitation services? No 8.5.3. Additional clarifications (if needed) Part 9: Provision of monthly financial support Fill in this part with information on the need to provide monthly financial support to people with permanent disabilities who are above the age of 18 years. The need is assessed in accordance with the degree of the permanent loss of the ability to work or the type and degree of disability of the person with a disability as established by a medical expert authority 9.1. Type of 1. Invalidity pension due to general disease pensions received 2. Invalidity pension due to an accident at work or occupational disease 3. Social invalidity pension 4. Other 9.2. Additional clarification (if needed) Part 10: Wishes of the person with disability and additional information Fill in this section with the wishes of the person with a disability to use (a) certain social service(s) or other support measures, the duration of that use and the wishes for development 10.1. What services/support measures does the person with a disability wish to use? 10.2. What is the motivation of the person with a disability for social integration? 10.3. Please note any other essential circumstances, if any: (First name and family name of the case manager/signature) ……………………………………………………………………………………… 250 The Self-assessment Form filled out by a person with a disabilities or her/his proxy SELF-ASSESSMENT FORM FOR PEOPLE WITH DISABILITIES This is a mandatory section to fill in: First name, patronymic, and family name of the person with a disability Date of birth Current address (City/town, municipality, region, street, Number, floor, apartment) Telephone number E-mail address Do you use (a) social service(s) Yes/No and/or personal assistance? Please specify: Do you receive any other type of Yes/No support? Please specify: First name and family name of a legal representative Contact details: address, telephone number, e-mail address Family and friends (family, 1. relatives, friends, other trusted 2. persons) Contact details of the family 1. members or friends: address, 2. telephone number, e-mail address General practitioner/medical specialist – contact details: first name and family name, telephone number NMEC/TMEC /MCC: Yes/No Type, No and date of the document: 251 Another medical document: Yes/No (Fill in if applicable) Type, No and date of the document: Percentage of long-term reduction in the ability to work /type and degree of disability, including the need for assistance by another person Intellectual insufficiency Yes/No If yes, please specify: Physical insufficiency Yes/No If yes, please specify: Mental insufficiency (dementia, Yes/No autism spectrum disorders, behavioral or personality If yes, please specify: disorders, etc.) Sensory insufficiency Yes/No (Sight, hearing, etc.) If yes, please specify: Other diseases Yes/No If yes, please specify: What services/support measures would you like to use? (Please indicate) 1. Monthly financial support Yes/No 2. Targeted aid for auxiliary aids and tools, equipment and medical devices Yes/No 3. Targeted aid for the purchase of a private motor vehicle Yes/No 4. Targeted aid for adaptation of the home Yes/No 5. Targeted aid for balneological treatment and/or rehabilitation services Yes/No 6. Targeted aid for renting municipal housing Yes/No 7. Use of personal assistance Yes/No 8. Use of social services Yes/No 9. Support for education Yes/No 10. Support for employment Yes/No 11. Other support measures – please specify: Need for personal assistance Do you need personal assistance? Yes/No If yes, please specify: 252 Fill in the next sections V-VII in only if you have indicated that you would like to use personal assistance I. Motor functioning How do you manage: Please tick each correct answer To use your hands 1. I use my hands on my own yes no 2. I can open and close the door yes no 3. I can hold and move a cup/glass yes no 4. I can turn the water tap on and off yes no To make fine 1. I can make fine movements with my hands yes no movements with your 2. I can cut with scissors yes no hands 3. I can button and unbutton yes no 4. I can draw with a pencil yes no To use your feet and 1. I use my feet and legs on my own yes no legs 2. I can walk yes no 3. I can crouch yes no 4. I can stand upright yes no To move your body 1. I move my body on my own yes no 2. I can turn in the bed yes no 3. I can sit up from a lying position yes no 4. I can stand up from a sitting position yes no To move around your 1. I move around my home on my own yes no home 2. It is difficult, but I move around the house yes no 3. I move around the room only yes no 4. I move at a minimal distance yes no To walk short distances 1. I walk on my own yes no 2. I walk on my own up to 500 m yes no 3. I walk on my own up to 250 m yes no 4. I walk on my own up to 50 m yes no To climb up and down 1. I climb up and down the stairs on my own yes no the stairs 2. I climb one floor up yes no 3. I use vehicles on my own yes no 4. I climb up and down the sidewalk yes no To overcome obstacles 1. I overcome obstacles outside my home on my own yes no outside your home, such 2. I move along a bumpy path on my own yes no as a bumpy path, a 3. I move along a slope outside home on my own yes no slope, and other barriers 4. I overcome barriers outside home on my own yes no Explanation of the nature of the problems: 253 II. Self-care How do you manage: Please tick each correct answer To maintain your 1. I maintain my personal hygiene on my own yes no personal hygiene 2. I wash parts of my body on my own yes no 3. I brush my teeth on my own yes no 4. I wash my hands on my own yes no 1. I bathe entirely on my own yes no To bathe 2. I wash my hair on my own yes no 3. I wash my body on my own yes no 4. I dry my body after a bath on my own yes no To go to the toilet 1. I reach the toilet and use it on my own yes no 2. I use the toilet on my own yes no 3. I manage with the clothes on my own yes no 4. I clean myself after using the toilet yes no To take food and drink 1. I eat and drink from a glass/cup on my own yes no 2. I serve my own food yes no 3. I use cutlery yes no 4. I recognize food yes no To dress and undress 1. I dress and undress on my own yes no 2. I can reach out and take my clothes yes no 3. I can select and put on seasonal clothes yes no 4. I recognize my clothes yes no To go to bed and get up 1. I go to bed and get up on my own yes no 2. I can lie down and pull the bedspread yes no 3. I can lift the bedspread and push it away yes no 4. I can get up after sleep yes no To take care of your 1. I take care of my health on my own yes no health 2. I use medical devices on my own (injections, oxygen, etc.) yes no (Not applicable to 3. I can dose medication yes no people with disabilities 4. I can take medication at the prescribed times yes no below the age of 18) Explanation of the nature of the problems: 254 III. Orientation and self-protection How do you manage: Please tick each correct answer To get your bearings 1. I get my bearings about myself, time, space and people yes no 2. I get my bearings about time – hour, day, night, month, year yes no 3. I get my bearings in space – community, street, buildings yes no 4. I recognize family and friends yes no To ask for help 1. I can ask for help on my own yes no 2. I can explain my situation verbally yes no 3. I can use body language to ask for help yes no 4. I can ask for help in a different way, e.g., by phone yes no 1. I can avoid risky situations at home and outside home on my yes no To avoid risky situations own 2. I can cross the street yes no 3. I can protect myself when I use utensils yes no 4. I can protect myself when I use detergents yes no With security at home 1. I have access on my own and security at home yes no 2. I can lock and unlock doors on my own yes no 3. I can open and close windows on my own yes no 4. I open the door to strangers yes no With the need for 1. I cope without special protection measures yes no special protection 2. I have exhibited risky behavior yes no measures 3. I have had situations of aggression and auto-aggression yes no 4. I have experienced passing out yes no Explanation of the nature of the problems: IV. Psycho-social functions How do you manage: Please tick each correct answer With concentration and 1. I can concentrate and sustain my attention yes no sustained attention 2. I can sustain my attention for 45 minutes yes no 3. I can sustain my attention for 20 minutes yes no 4. I can sustain my attention for 5 minutes yes no To observe social 1. I understand, accept and observe the social behavior rules yes no behavior rules 2. I observe the social behavior rules in an unfamiliar environment yes no 3. I observe social behavior rules in a familiar environment – a public building yes no 4. I observe social behavior rules in a familiar closed environment – kindergarten, school, workplace yes no 255 To organize your daily 1. I organize my daily life on my own yes no life on your own 2. I maintain social contacts on my own yes no 3. I manage with routine situations or issued in a familiar closed yes no environment outside home 4. I manage with routine situations or issued at home yes no Explanation of the nature of the problems: V. Social functioning How do you manage: Please tick each correct answer To use transport on 1. I use transport on my own yes no your own 2. I can get on and off a vehicle on my own yes no (not to be filled in by 3. I can travel on my own yes no persons with disabilities 4. I can choose an appropriate vehicle on my own yes no below the age of 12 years) To manage your own 1. I manage my own budget yes no budget 2. I can do shopping that is adequate to my needs yes no (not to be filled in by 3. I can pay utility bills and other costs on my own persons with disabilities 4. I can make decisions on how to spend the available funds yes no below the age of 12 yes no years) To do shopping 1. I do my shopping on my own yes no (not to be filled in by 2. I can visit stores and markets on my own yes no persons with disabilities 3. I can choose goods on my own yes no below the age of 12 4. I can pay for the purchases on my own yes no years) To use public services 1. I use public services on my own yes no (not to be filled in by 2. I can reach the service on my own yes no persons with disabilities 3. I can choose a service on my own yes no below the age of 12 4. I can use a public service if accompanied by somebody yes no years) Reception of 1. I receive information through all generally accessible forms of yes no information communication Reproduction of 1. I reproduce information through all generally accessible yes no information forms of communication Explanation of the nature of the problems: 256 VI. Activities in the home environment How do you manage: Please tick each correct answer With cooking 1. I cook on my own yes no (not to be filled in by I can make a sandwich yes no persons with disabilities 3. I can cook a single dish yes no below the age of 12 I can cook on my own for myself and other people yes no years) To keep daily hygiene at 1. I keep daily hygiene at home yes no home 2. I can clean and tidy up my home yes no (not to be filled in by 3. I can keep my clothes clean yes no persons with disabilities 4. I can keep daily hygiene at home to some extent yes no below the age of 12 years) Explanation of the nature of the problems: VII. Social relationships How do you manage: Please tick each correct answer To establish and 1. I establish and maintain social contacts on my own yes no maintain social contacts 2. I establish and maintain social contacts in an unfamiliar closed environment outside home yes no 3. I establish and maintain social contacts in a familiar closed environment outside home yes no 4. I establish and maintain social contacts in my home environment yes no To participate in 1. I participate in various activities with other people on my yes no activities together with own other people 2. I take the initiative to participate in activities with other yes no people 3. I am interested in participating in activities with other people yes no 4. I have the opportunity to participate in activities with other people yes no Explanation of the nature of the problems: Fill in this section if you would like to receive support for education and/or aid for the purchase of a private vehicle What educational institution are you attending currently? (Underline the correct answer) What educational level are you learning for currently? (Underline the correct answer) 257 What form of education/training are you attending currently? Underline the correct answer 1. Creche 2. Kindergarten 3. School 4. Special school 5. Centre for special educational support 6. Other. Please specify: I am not involved in training. Please specify the reasons: 1. Pre-school education 2. Primary education - Elementary – grades I-IV - Junior high (middle) school - grades V-VII 3. Secondary education - Lower secondary school (special profile/vocational)- grades VIII-X - Upper secondary school (special profile/vocational) - grades XI-XII 4. Other. Please specify: 1. Full-time 2. Evening classes 3. Extramural 4. Individual 5. Independent 6. Remote 7. Hybrid 8. Learning on the job (dual education system) What support are you asking to receive? Specify: Fill in this section if you are of working age and you would like to receive support for employment and/or targeted support for the purchase of a private vehicle Are you working Yes/No currently? Yes, a full-time job (Underline the correct Yes, a part-time job answer) Yes, a liberal profession Yes, a supported job Yes, a job at a specialized enterprise Yes, a job at a social enterprise Yes, a job at a Protected Employment Centre Yes, other Are you seeking a job? Yes/No Please specify: What support would you like to receive? Please specify: 258 Fill in this section if you would like to receive social services Can you rely on the Yes/No support from other If yes, from whom? persons – 1. Partner/spouse family/household 2. Relatives members and/or 3. Friends, acquaintances others? 4. Others, namely: (Underline the correct answer) What does this support entail? Do you need Yes/No professional care? If yes, what type of support? (Underline the correct 1 Social services answer) 2 Another type of specialist, namely: 3 Other: What would this support consist of? Please describe. Fill in this section if you would like to receive targeted aid for adaptation of the home Are your current living Yes/No conditions appropriate? If yes, please explain: What has the average Please explain: monthly income per family member been for the last 12 months? Have you received Yes/No targeted aid for the adaptation of the home If Yes, when: in the last 10 years? What adaptation of the Please clarify: home do you need? Fill in this section if you would like to receive targeted aid for paying municipal housing rent Do you have a contract Yes/No for municipal housing accommodation? If Yes: 1. Who has signed the contract (first name and family name): 2. Relationship of this person to the person with a disability: - parent of a child with disability; - legal representative of a person with permanent disability who is placed under full legal disability 259 What is your status? 1. I live on my own 2. Child with permanent disability 3. Person placed under full legal disability (incapacity) Other: Additional information: Fill in this section if you would like to receive targeted aid for auxiliary aids and tools, equipment and medical devices (AATEMD) Do you use AATEMD? Yes/No If yes, what type: Is the need for using Yes/No AATEMD established in a medical expert If yes, what type(s): opinion? Additional information: Fill in this section if you would like to receive targeted aid for the purchase of a private motor vehicle (PMV) Do you own a PMV Yes/No currently? If yes, please describe: Have you received Yes/No targeted aid for the purchase of a PMV for If yes, when: the last 5 years? Additional clarifications: Fill in this section if you would like to receive targeted aid for balneological treatment and/or rehabilitation services Do you need escort to Yes/No use balneological treatment and/or rehabilitation services? Additional clarifications: Fill in this section if you would like to receive monthly financial support 260 What type of pension 1. Invalidity pension due to general disease do you receive? 2. Invalidity pension due to an accident at work or occupational disease 3. Social invalidity pension Another type: Additional clarifications: What is your motivation for social integration? Other essential circumstances, if any: I am aware of my criminal and civil liability for providing untrue information. First name and family name and signature of the person with a disability First name and family name and signature of the legal representative: Date: 261 References 12 principles of the good governance of the Council of Europe. https://www.coe.int/en/web/good- governance/12-principles/ A. Posarac et all. 2021. Strengthening Disability System in Bulgaria: Review of EU relevant practices regarding creation and functioning of disability agencies. © World Bank Bickenbach J, Posarac A, Cieza A and Kostanjsek N. 2015. Assessing Disability in Working Age Population – A Paradigm Shift: from Impairment and Functional Limitation to the Disability Approach. Report No: ACS14124. Washington, DC.: The World Bank. Council of Europe. 2002. Assessing Disability in Europe – Similarities and Differences. Integration of People with Disabilities. ISBN 92-871-4744-2. Strasbourg. Disability, Work and inclusion in Ireland, 2021, Sickness, Disability and Work: Breaking the Barriers. A Synthesis of Findings across OECD Countries. 2010. E – Research Consortium, Elaboration of a Subsequent Assessment of the Effect of the Active Labor Market Policy, Financed by State Budget Resources at Individual Level (Net Effect) for 2015, Sofia, 2017, https://www.mlsp.government.bg/uploads/26/zaetost/final-report-print-en.pdf E – Research Consortium, Elaboration of a Subsequent Assessment of the Effect of the Active Labor Market Policy Financed by State Budget Resources at Individual Level (Net Effect) of the Programs and Measures, Included in the National Employment Action Plan for 2017, Sofia, 2019, https://www.mlsp.government.bg/uploads/1/net-effect-final-report-en1.pdf ILO. 2019. Promoting Employment Opportunities for People with Disabilities Quota Schemes. Volumes 1 and 2. Geneva. https://www.ilo.org/global/topics/disability-and- work/WCMS_735531/lang--en/index.htm, and https://www.ilo.org/wcmsp5/groups/public/--- ed_emp/---ifp_skills/documents/publication/wcms_735532.pdf Malo, M. and Pagan, R. 2014. Hiring workers with disabilities when a quota requirement exists: The relevance of firm’s size. https://www.researchgate.net/publication/257021597 Posarac, A. (2020). Disability Policy and Disability Assessment System in Lithuania © World Bank. Posarac, A., Bickenbach, J., and Celmina, E. (2020). Disability Policy and Disability Assessment System in Latvia © World Bank. Public Administration Characteristics and Performance in EU 28: Bulgaria, European Commission, 2018. https://op.europa.eu/en/publication-detail/-/publication/15cd2969-9605-11e8-8bc1- 01aa75ed71a1/language-en Sick on the Job? Myths and Realities about Mental Health and Work. 2011. The World Health Organization and The World Bank. 2011. The World Report on Disability. Geneva, New York and Washington, D.C. https://www.who.int/teams/noncommunicable-diseases/sensory- functions-disability-and-rehabilitation/world-report-on-disability 262 United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) 2006. https://www.un.org/disabilities/documents/convention/convoptprot-e.pdf. WHO. 2015. World Report on Aging and Health. Geneva, 2015. https://www.who.int/ageing/publications/world-report-2015/en/ WHO. 2020. Decade of Healthy Aging. Baseline report. Geneva, 2020. https://www.who.int/publications/m/item/decade-of-healthy-ageing-baseline-report World Health Organization. 2001. International Classification of Functioning, Disability and Health (ICF). https://www.who.int/standards/classifications/international-classification-of-functioning- disability-and-health 263