Clinical pathways – the Bulgarian approach



Over the past 20 years, the use of clinical pathways has increased rapidly in many countries. The implementation of clinical pathways, i.e., using evidence-based gold standards in diagnostic and treatment algorithms, is aimed at optimising patient care, improving the intermediate and discharge outcomes, as well as reducing the inpatient length of stay and the overall costs. Bulgaria introduced CPs in 2000, but failed to achieve the goals it had initially set. To analyse the potential reasons for this failure, our study aims to describe the approaches used in Bulgaria to develop CPs and the actual application of CPs in Bulgaria.


We analysed Bulgarian literature and official government publications and utilised the author’s first-hand experience, working as a consultant to various governmental organisations. To evaluate the Bulgarian CPs we compared the Bulgarian approach with internationally acknowledged methods to devise CPs.


In Bulgaria, the requirements for understanding the procedures covered by CPs, for defining the rules of treatment, for monitoring deviations, for refining the rules and ultimately for modifying practice behaviour have not been complied with while developing the clinical pathways. Bulgaria uses CPs as an instrument for resource allocation to inpatient health-care providers rather than as a tool for improving health-care quality.


Despite the broad scope of discussion in Bulgaria and the experience and knowledge gained in the past 5 years, the utilisation of clinical pathways for improving the quality of medical care is still unsatisfactory. Bulgarian health decision-makers merely used the title of a tool with proven qualities in managed care and efficient resource utilisation without implementing it according to international standards.

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clinical pathway


diagnosis related groups


length of stay


Ministry of Health


National Framework Contract


National Health Insurance Fund


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We want to thank Alexander Rosen for his linguistic support.

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The authors disclose any relevant associations that might pose a conflict of interest.

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Correspondence to Milka Ganova-Iolovska.

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Ganova-Iolovska, M., Geraedts, M. Clinical pathways – the Bulgarian approach. J Public Health 17, 225–230 (2009).

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  • Clinical pathways
  • Bulgaria
  • Application
  • Resource allocation