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CONTENTS

Acknowledgements

Introduction

Profile of Bulgaria

Legislation

Care and Service Provision

Dynamics within the NGO Sector

NGO Activity in the Field of Mental Health

Other Agencies

In Conclusion

Appendix 1- Public Health Act (1973)

Appendix II - Rules for Application of the Public Health Act

Appendix III - Constitution of Republic of Bulgaria

Appendix IV - Schedule of Visits and Meetings

Appendix V - References
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ACKNOWLEDGMENTS

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

In addition to those who met with me on a professional basis, I wish to extend my

thanks to everyone who allowed me to share in a little part of their life. In
particular my thanks go to the service users who took the risk to meet with me
and answer my questions and to the families of Raina Vladimirova, Emilia
Dimitrova and Amelia Nikolova who so warmly welcomed me into their homes. I
am also indebted to Alia Veder for all her efforts on my behalf regarding the
arranging of meetings, accommodation, transport etc.
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INTRODUCTION

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

Development Officer with InterMinds. This visit followed on from a visit made to Sofia
in July 1997 by Peter Kampman, the Chief Executive of InterMinds. There has been
continued contact with Bulgaria since then, mainly through the Neuroscience and
Behaviour Foundation, and increased interest in the possibility of assistance from
InterMinds. However it became clear that, before committing the organisation, we
needed greater clarity about the real situation of mental health in Bulgaria.
My remit was to form an overview of mental health care and service provision in
Bulgaria and, more specifically, to establish as clear and accurate a picture as possible
of the non-governmental sector working in Bulgaria in the field of mental health. To this
end I met with a number of people in senior positions working with NGOs from Sofia,
the capital of Bulgaria, and from Targovishte and Shumen, two smaller towns in the
west of Bulgaria. I also had the opportunity to meet with service users in Targovishte,
in-patients and outpatients at Shumen Psychiatric Unit, staff from the Centre of
Hygiene in Sofia and the Chief Advisor to the Minister of Social Affairs with
responsibility for NGO liaison. Furthermore I visited the Psychiatric Unit attached to
Shumen Hospital and psychiatric wards within Targovishte Hospital.

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

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

• Clarifying the areas of interest of the various NGOs.

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

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

• Exploring as far as possible what differences exist between NGO activity in Sofia
and in rural areas.

• Remaining open to the culture of the country.

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

• Collecting information regarding other international involvement and presence in

this field.

3
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One week is a relatively short period in which to collect and explore the information
necessary to give an accurate picture of NGO activity in the field of mental health in
Bulgaria. I did however leave with some fairly clear impressions, thanks largely to the
wonderful energy, willingness and enthusiasm of many of the people with whom I met.
Most of those people were juggling full time and demanding jobs along with family and,
what often appeared to be an almost full time commitment to their NGO involvement.
And yet they readily and willingly fitted in extensive meetings with me and took the time
and trouble often to come prepared with information and details about their work and
projects or to ensure that this was passed on to me later.

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

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

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

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

There is a growing belief among some people however that this seemingly supportive
attitude of parents is evidence of the culture of paternalism that has been prevalent in
Bulgaria over centuries. As such it hinders and disables rather than empowering and
enabling those whom it purports to assist. Paternalism and patriarchy perpetuate a
climate of helplessness in the face of control and power.

Alongside the above-mentioned energy and motivation to develop amongst some

people, there is a strong feeling of frustration at the lack of the guidance and direction
to which the country as a whole has been accustomed for so long. Where there was
once paralysing control, there is now nothing. The new government is concentrating its
energies on developing appropriate policies and legislation but this of course takes
time. In the meantime the people have for so long been used to being “taken care of”,
that it is hard to begin to take responsibility again. So there is almost a feeling of

4
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vacuum and nothing happening. Unemployment figures are high and there is little
accessible support from the state for people in need. Suicide figures quoted from
research done by an NGO in Sofia suggest that in 1997 about 1400 people commit
suicide every year with the number of attempts figuring between 5 and 10 times more
(see “Budnina” Foundation).

In the area of mental health, there is no existing specific legislation although the
Ministry of Health is currently exploring and discussing the, for Bulgaria, new concept
of Mental Health Reform. Equally there are no mental health policies in action.
However a number of key individuals working in the field of mental health have
apparently been asked to address the need to develop relevant policies. With regard to
introducing the concept of community care, there are obvious difficulties due to the still
enormous stigma connected with mental health issues, in addition to strong opposition
from older psychiatrists who wish to perpetuate the existing, traditional hospital based
system of care. However there is a feeling of optimism about support from the present
Government in this area.

In Bulgarian culture there is no history or experience of user or carer initiatives. The

very idea of a patient being in any way active in his/her own life as a user of services is
still very new. There is very little continuity of care at a professional level, so
relationships are not built between the patient and professionals and the control
remains firmly in the hands of the professional who is currently involved.

There are some NGOs working in the field of mental health in Bulgaria, with varying
degrees of success and activity. There is awareness amongst most of the groups with
which I met, of the importance of networking and pooling resources. At the same time
there is an atmosphere, especially in Sofia, of mistrust and possibly jealousy between
some of the NGOs regarding the securing of outside support and funding. There is no
effective national association or organisation as yet. I shall provide details in this report
of the specific areas of activity in which some of the existing NGOs are involved and of
a number of project proposals. I also had the opportunity to visit a psychiatric unit
attached to one of the regional hospitals at Sumen near the Black Sea, to meet with
users who are actively involved in the work of an NGO based at Targovishte and to
meet with Department Heads at the Centre of Hygiene in Sofia.

5
 PROFILE OF BULGARIA

The Republic of Bulgaria is situated in the south eastern part of the Balkan Peninsula.
With a population of 8.4 million, Bulgaria covers an area of approximately 111,000
square kilometres. To the south Bulgaria shares borders with Turkey and Greece and
to the west one finds Serbia and the Republic of Macedonia. Romania lies to the north,
separated from Bulgaria by the river Danube and the Black Sea forms a natural eastern
border. The fifteenth largest country in Europe, Bulgaria lies at the centre of a region
that is in the process of dynamic change and development. Since 1989, the country has
undergone a series of rapid and at times turbulent political changes.

Historically Bulgaria has experienced a number of influences over the years from other
cultures. Following the invasion of the Bulgars in the 7th century AD and their gradual
adoption of the culture and language of the conquered Slavs, Bulgaria became a
significant power in South East Europe. Despite coming under Turkish rule in 1396, the
Bulgars succeeded in retaining their national identity over the centuries until they once
again became independent in 1908 under the Saxe-Coburg ruler Ferdinand, who took
the title of tsar. He however was forced to abdicate in 1918 after supporting the Central
Powers. Bulgaria aligned itself with Germany in both World Wars. In 1944 it was
occupied by the Soviet Union and power was seized by the Fatherland Front, a left-
wing alliance, which formed a pro-Soviet government that declared war on Germany. In
1946 a People’s Republic was proclaimed and Bulgaria became one of the Soviet
Union’s satellite states. Under a new constitution in 1971 Todor Zhivkov became head
of state until pressure for reform forced him to resign in 1989. Democratic multiparty
elections were held in 1990, resulting in victory for the former Communists, now styled
Socialists. Further elections in 1991 resulted in victory for an anti-Communist coalition
led by Filip Dimitrov; a broader coalition took over in 1992. In 1994 the Socialists were
re-elected and Zhan Videnov became prime minister. A non-socialist president, Peter
Stoyanov, was elected in 1996. In 1996-97 economic crisis led to mass protests
against the Socialist government. Parliamentary elections held in 1997 were won by a
centre-right coalition led by Ivan Kostov.

As a parliamentary republic, Bulgaria is governed by a one-chamber parliament called

the National Assembly to which elections take place every four years. The President is
the head of state and is assisted by the Council of Ministers, an administrative body
that directs the domestic and foreign policy of the country. For the purposes of
administration, the Republic of Bulgaria is divided into 278 municipalities and 9
regions. The municipality is a legal entity and has the right of ownership and an
independent municipal budget. The municipal council is the local government authority
in the municipality and determines the policy for the construction and development of
the municipality. The regions are administrative-territorial units for carrying out regional
policy and implementing state government. The region’s management is effected by a
regional governor and regional administration and their maintenance costs are paid by
the state budget. The regional governor is appointed by the Council of Ministers and
the deputy regional governor by the Prime Minister.

In 1991 Bulgaria chose the path of rapid and radical economic reform, joining the
International Monetary Fund and beginning the process of adapting to a market
economy. Privatisation began in Bulgaria in 1993 with an ambitious mass privatisation
programme being adopted by the government in 1996. With regard to foreign
investment, Germany, the Netherlands and then the UK are the three largest investors
in Bulgaria. Foreign investment is important evidence of Bulgaria’s determined move
towards European integration of which the first step was the signing in April 1993 of the
Europe Association Agreement. This Agreement came into force in February 1995 and
contains intentions and resolutions regarding different aspects of the political,
economic, social and cultural integration of Bulgaria into the structures of the European
Union. This document also highlights the breakdown of trade barriers and includes the
intention to move towards the harmonisation of EU and Bulgarian legislation.

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

Bulgaria does adhere to a policy of a minimum monthly wage that is subject to regular
changes by the government according to the rate of inflation. Some employment
conditions are, by western standards, fairly progressive. For example maternity leave
entitlement for a first child is 120 days plus paid leave until the child reaches the age of
2 years so that the mother can be directly involved in raising her child at home. Public
social security, (social security tax is obligatory for both employers and employees),
also covers paid leave in order to take care of a sick child or family member. Despite
these provisions, many couples make a conscious decision to have only one child in
order to be sure of being able to support their family in the current economic climate. I
met a number of women during my visit to Bulgaria, and heard of others, who had left
the decision to have even one child too late, due to a very real fear of poverty. The
family unit still plays an important part in Bulgarian culture although divorce and single
parent families are becoming increasingly common here as elsewhere in Europe and
the west.
 LEGISLATION

There is an urgent need for change in legislation in Bulgaria as at present there is no

specific legislation concerning mental health or psychiatry. The immediate need and
first step, as seen by concerned professionals working in the field of mental health, is to
sensitise the government to the need for change and to then assist in preparing the
government for this change. The current General Health Act, which was passed in
1973, contains one paragraph relating to the involuntary treatment of patients (see
Appendix I, Article 36). Another section deals in more detail with compulsory measures
for offenders with mental illness who are therefore considered incompetent (see
Appendix I, Articles 59-67). Special regulations regarding custodial measures for the
mentally ill are outlined in the General Health Act. Where a mentally ill person is a
legal offender, the provisions of the Penal Code of 1968 are complied with. Although
different texts are available, including information from abroad, the criteria for
assessment of legal incompetence lack clarity. Up until now there have been no
mental health policies but the Ministry of Health is currently discussing new concepts of
Mental Health Reforms and have asked a number of key workers in the field to address
the need for policy making. Dr Toma Tomov is one of the professionals who has been,
and continues to be, instrumental in the preparation of a new programme of reform for
psychiatric care in Bulgaria. Dr Tomov is the Head of the Department of Psychiatry at
the University Hospital Alexandrovska in Sofia, a member of the WHO Expert Panel in
Mental Health and an advisor to the United Nations for Mental Health Programme. He
is also the elected President of the Association of Mental Health Reformers in Eastern
Europe that is to be based in Sofia.

Over the past 25 years, various texts and documents have been prepared regarding
psychiatry and mental health in Bulgaria and including some comparative studies
based on a number of other countries. Some of the more recent studies have been
translated into English. However there has been no change in legislation since the
1970s. Existing legislation closely resembles the traditional legislation in a number of
other countries of Eastern Europe. This is beginning to change elsewhere but there is
the feeling that Bulgaria is being left behind. Now, with increasing pressure from the
Council of Europe, the State will have to implement changes.

Apparently there are now many organisations and individuals in Bulgaria with an
interest in mental health issues. However only a few are active due mainly to post-
communist problems, lack of funding and lack of motivation. There is some recognition
that the lack of money is, at present, of secondary importance and that the major
difficulty is to change the prevailing attitudes and to move on from a survivalist culture
to one of development. In recent years, most psychiatrists for example, directed their
efforts and energy towards ensuring their own survival by means of securing an
immediate income. In 1990, on the initiative of the Minister of Health, a group of five
professionals involved in the field of psychiatry and mental health began to work on a
project to prepare a draft for a new Mental Health Act. The draft, which has been
translated into English, was at the stage of being presented but was withdrawn by the
government. Of the working group, only three members were actively involved along
with some input and assistance from the Geneva Initiative on Psychiatry. Now only one
member remains actively involved with the aims of the project. As the president of the
Bulgarian Psychiatrists’ Association he hopes to find others to assist him and that they
might be able to influence mental health legislation.

The focus of the project was to address Human Rights in Mental Health and it was
based on ten principles outlined in 1991 by the United Nations as guidelines for mental
health legislation. It was believed that these principles provided good ground for the
formation of cross-national legislation in this area although they do identify the difficulty
caused by national differences. Also, as guidelines, these principles are based on
hospital care rather than the possibility of community care. The remaining member of
the working group for the project expressed some considerable interest as to whether
these principles are being successfully implemented somewhere and whether they are
in fact workable as instruments.

Another aspect of the draft project for legislative reform looked at the concept of
informed consent. It was recognised that a more detailed proposal was needed, as the
notion of informed consent itself is still undeveloped. Also the concept of confidentiality
needs to be addressed in all areas of care. With regard to the issue of compulsory
treatment, there are discussions as to whether this should come under the jurisdiction
of a Mental Health Act or the penal system. At present, where an individual is
considered psychotic or of danger to him/herself or others, anyone can apparently
initiate the perceived need for treatment. This is followed by a long process of
assessment, over a period of months usually, culminating in a court decision. The
individual concerned is not confined during this period. He/she only has the right to
representation in court and not throughout the proceedings prior to a court hearing.
The 1991 Constitution of the Republic of Bulgaria states “Every citizen has the right of
defence when his rights or legal interests are menaced or violated” (see Appendix III,
Article 56). However although this right is specified in law, such representation does
not usually happen. The possibility of representation during a court hearing or of
appeal against the verdict, rarely happen and are relatively ineffectual. Once the
prosecutor has proposed compulsory hospitalisation, the court rarely rejects the
proposal. In 1995, for example, out of 2735 proposals, 2407 resulted in a court order
for compulsory admission i.e. 88%. Between 1993 and 1995 less than 2% of such court
decisions were appealed against. There is an emergency process involving police
restraint and confinement if the risk of danger is considered to be immediate.
Confinement is limited to a twenty-four hour detention in the first instance and the court
prosecutor must be informed during this period in order that an emergency decision
can be made on the case. I spoke to a number of concerned professionals (e.g. Boris
Boyadjiev, president of the Bulgarian Psychiatric Association and the Director of the
National Centre for Interdisciplinary Human Studies) who expressed a strong wish that
there should be an amendment to the existing law to state that organisations involved
with advocacy and patients’ rights should have the right to offer their services and to
ask for information on such cases, with the consent of their clients. Although at present
this is not forbidden, it does not happen and is certainly not facilitated. There is no
independent body such as an ombudsman in Bulgaria. I heard further about the need
for a precise formulation of the process for compulsory treatment based on 1) the
dangers of the illness and 2) the provision of help whether the individual agrees or not
when the individual is clearly not competent to decide regarding his/her immediate
need. When there is a risk of harm, there is a need to distinguish between these two
issues. The current procedure for compulsory treatment of someone with a recognised
mental health difficulty is the same as in the Penal Act.

The draft for legislative reform also makes reference to the issue of Guardianship. This
does exist in Bulgaria for people who are considered to be “totally mentally
incompetent”. There is a chapter of the draft proposal regarding temporary
guardianship for people who need representation because of mental health difficulties
that are temporary and short term.

NGO Influence on Legislation

In Bulgaria, there has been little official recognition of non-governmental organisations

(NGOs) and therefore no consultation with them. No-one asks NGOs for their opinions
or that they share their information and experience. Professionals and specialists will
be invited to give their opinions but NGOs find it very difficult to influence any
legislation, as they are not consulted. There is a growing belief now that there is a need
for some body to be established in order to ensure contact and communication
between NGOs and government agencies. There are currently moves in Sofia, initiated
by an emergent mental health NGO, to establish a Consultative Council for this
purpose. It is hoped that any mental health legislation may be passed through this
Council. There was the feeling when I spoke with people earlier in 1998, that action in
this area was urgently needed, as there was a package of social legislation about to be
passed, part of which would relate specifically to mental health. This is certainly seen
as progress since previously there has only been legislation relating to general health.

Consultative Council

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

The following paragraph describes the proposed system for building a Consultative
Council.

A working group will be established, starting with representatives from those NGOs
already interested in the aims of the National Association and possibly also involving
representatives from some government agencies. This group will look at legislation that
is already in existence e.g. social laws and will aim to promote the interests of NGOs
with regard to legislation. Through the Council, legislation can be discussed and
suggestions for amendments or changes can be proposed and passed to the relevant
government body. At a later date representatives will be invited from NGOs to sit on the
Consultative Council itself. Rumen Ratchev believes that such a Council could succeed
if it is established now in the current political climate that is more democratic with
regard to the establishing of a civil society.
Government Attitude towards NGOs

I had the opportunity, while in Sofia, to meet with Mario Sarbinov, the newly appointed
Chief Advisor to the Minister of Social Affairs who has particular responsibility for co-
ordinating meetings and liaising between NGOs and the Ministry. This is a very recent
post, set up in July 1997, which has been specifically created in order to facilitate
interaction between the government and the NGO sector. Mr Sarbinov informed me that
the Government is now actively engaged on a programme of developing legislation with
the recognition that it must then address the need to form and implement realistic and
effective policies. According to Mario Sarbinov there are a number of charities and
NGOs across Bulgaria that are involved in providing humanitarian aid mainly for
vulnerable groups such as children and the elderly. They exist primarily to distribute
some aid and to encourage international agencies to send aid. Such organisations are
more active and developed in Sofia than across the rest of Bulgaria. However NGOs
are limited at present as there is no specific law relating to their activities. There is a
book that is in the process of being printed which will give details of different legislative
acts in existence that can assist NGOs in their work.

Mr Sarbinov spoke also of a Consultative Council of NGOs which is currently being

established in order to influence policy. I am unclear as to whether or not this is the
same consultative body as that which Rumen Ratchev is involved in establishing. This
Council began to be formed at the beginning of 1997 to assist in the short term with the
distribution of humanitarian aid. Now the idea is to develop this body so that it might
effectively assist with legislative reform. Often such groups are formed with no clear
idea of their actual remit and with little concept of how to collaborate with local
government. Also there has been a tendency to involve people from within the state
system who are neither popular choices nor appropriate, as they usually have no
relevant experience. The system for establishing consultative councils was there but
the practice of implementation was not good. There is good reason to hope that, with
this awareness and with the creation of posts such as that of a Chief Advisor with
specific responsibility to work with NGOs, the situation will improve.
 CARE AND SERVICE PROVISION

Health reform is beginning in Bulgaria. The intention is to establish a service similar to

that in the UK with one central state fund and then a system of local general
practitioners. As yet though the central health fund has not been collected and there is
no provision within the existing system of health care for psychosocial care. Under the
proposed new system a psychiatric patient would be referred by his/her GP to a
consultant psychiatrist and then be sent back to the GP for care. If a patient is not
referred by a GP then he/she has to pay the hospital for treatment. Similarly if there is
no direct hospital referral for specialist care or treatment then the individual needs to
pay also for this service. Sometimes this means that people pay three times for
necessary care, firstly through social insurance, secondly to the hospital and thirdly to
a specialist practitioner.

There is no real follow up or continuity of care at present. Most patients do not have
their own key psychiatrist but usually see a number of different people. Attempts are
being made to change this by identifying one doctor to build a relationship with a
patient and then to co-ordinate any necessary care. However GPs are not sufficiently
trained as they receive only six months of psychiatric training covering a series of eight
exercises. Many qualified psychiatrists only in fact receive biological training with no
opportunity for alternative training. There are very few alternatives available to the
traditional hospital based care. I visited one NGO (Bulgarian Brief Therapists Society),
which has established a Day Centre Service at Sofia Hospital. The Centre uses
hospital premises although it is an NGO but there is ongoing conflict because the
Centre tries to use less drugs and to work with alternatives to traditional psychiatry and
the hospital tries to insist on the use of drugs. Also people are afraid to use the Day
Centre Service as this involves coming to hospital premises; they would prefer to see
the therapists elsewhere. Many attempts are being made by this NGO and others to
find funding to provide alternatives to psychiatry as a means of managing mental
illness.

There is a growing recognition amongst mental health NGOs of the importance and
need for community-based initiatives to provide alternative care and services to the
existing hospital based system. At present psychiatric care continues to be dispensed
by psychiatric hospitals, clinics attached to university medical departments,
dispensaries, and health centres, specialist annexes attached to general hospitals.
There is now a more optimistic feeling about the possibility of support from the present
government and NGOs are trying to introduce a concept of care where community care
plays a valued part. There is still however strong opposition from the older more
traditional psychiatrists who wish to perpetuate the existing hospital based system of
care. The number of hospital beds has been reduced for both short and long stay
patients, probably for economic reasons. This has inevitably caused concern amongst
hospital staff regarding the likely loss of jobs. There might be the possibility for
redundant staff to work on community projects if funding can be found. The economic
picture in Bulgaria has undergone a number of drastic changes in recent years and
where, prior to 1989, professionals like doctors and lawyers were amongst the most
highly paid now they are not. A qualified doctor or psychiatrist now earns on average
100,000 leva per month, approximately £33.00. In comparison a retirement pension is
approximately 50,000 leva per month and a prescription costs 44,000 leva. There is no
specific training for psychiatric nurses in Bulgaria although there are some incidental
courses. Up until five years ago, there were no clinical social workers in Bulgaria. The
University of Sofia does now however provide specialist psychiatric training for social
workers. There are though large gaps in existing training both for social workers and
psychiatrists. Patient’s rights and the concept of an interdisciplinary approach to care
are only just beginning to develop in Bulgaria. Such aspects are missing from existing
training. WHO compiled a database in 1994 that seeks to compare psychiatric care
and service provision in Europe over the ten years from 1982 to 1992. Statistical
information, provided in the data-base, referring to the ratio of psychiatric staff
(psychiatrists and psychiatric nurses) to heads of population, indicates a considerable
difference between the levels of human resources allocated to the area of mental
health in Bulgaria (and other countries of Central and Eastern Europe) compared with
countries in Northern Europe. Some doubts have been expressed as to the accuracy
of some of the figures and the picture that they form. However, it appears clear that
there has been little increase in recent years in the level of staffing working in the field
of mental health in Bulgaria.

From what I could determine, it is very rare for any needs assessment to take place
prior to care being recommended. I spoke to two psychiatrists in Shumen who said that
they were not aware of any studies or surveys being carried out in order to evaluate
whether or not the services provided are in fact relevant to the needs of the service
users. Hospitals are regional and cover perhaps one hundred municipalities. The
hospitals, along with the care provided in the community by the local municipality, are
funded under a government-managed budget. However, given that there appears to be
no clear relationship between the hospitals and community care, or what is known as
municipality care in Bulgaria, it is very difficult for patients to leave hospital and move
into the community. Many professionals to whom I spoke feel that the state has a clear
responsibility to provide patients with appropriate care but that this responsibility is not
being met under the current system.

Existing Services

As there is no specific mental health legislation, equally there are no relevant or

effective policies for ensuring appropriate care or support for people with mental health
difficulties. There is little or no evidence of any needs assessments being carried out
nor of any surveys or studies to determine whether or not existing services are relevant
to the needs of those receiving them. Social Care Homes exist for certain groups of
vulnerable people i.e. the elderly, those with dementia, the physically ill, children with
learning difficulties. Support or care is provided by carers and paid for by the state.
Some of the carers have special training though most do not. A training school has
apparently now been established in north-west Bulgaria to provide training for social
care workers. Social Care Homes are the responsibility of the Social Work or Social
Welfare departments but there is no provision within this system for people with mental
illness.
Under the communist regime, everyone had the right to work if they could and it was
the government’s responsibility to find appropriate work (see Appendix III, Article 48.1).
This is no longer the law, although many people want this to change. There used to be
co-operatives where invalids and mentally ill people lived and worked together (see
Appendix II, Part 5: Work Therapy). Such places no longer exist. With no real social
policy in place there is a very high rate of unemployment throughout the country, even
for those without any difficulty. The government apparently does not support the
possibility of supported accommodation projects. Any money given for such projects is
liable for tax so it becomes too expensive for such projects to exist.

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

Hospitals

In Bulgaria in 1997 there were 15 psychiatric hospitals, accounting for 59% of all
psychiatric beds. No new hospitals have been opened since 1975. The hospitals
provide, on average, between 400 and 500 beds each, with Radnevo Psychiatric
hospital being the largest such institution (620 beds). Only 2% of beds are reserved for
patients experiencing senile dementia, although available data suggests that around
9% is required in order to ensure adequate provision. The geographical distribution of
psychiatric hospitals in Bulgaria is uneven. Hospitals are allocated according to
population figures in each region rather than according to need. Some hospitals
however accept patients from a number of regions. Thus in the region of Lovetch, there
are 4 hospitals providing 1785 beds, while in the region of Burgas there are no
psychiatric hospitals.

The conditions in hospitals and psychiatric units are very bad. I visited one hospital for
psychiatric patients and also one separate psychiatric unit. In addition I heard from a
number of patients and professionals about the conditions in other hospitals. From all
reports there appears to be little difference to be found, regardless of whether the
hospital is in a city or in a rural area. Priority in terms of resources and expenditure
from allocated budgets appears to be given to general hospitals as opposed to
psychiatric hospitals or units. Premises for psychiatric services are most often
temporary and inappropriate, being adapted for example from old school buildings, a
prison, a monastery etc but they soon become accepted as permanent.

The complaints were similar, focusing on not enough money, not enough food,
insufficient medication, inadequate heating, insanitary washing and toilet facilities, little
or no laundry facilities etc. Meals are often inadequate and provide little nutritional
content causing patients to rely on friends and family to bring them something to eat.
One example of a main meal described by a patient, consisted of a tomato with bread.
In many hospitals the heating is only switched on in November, regardless of the
temperature. Heating is provided for two hours at a time and then turned off for two
hours. As a result, patients complain that although they are perhaps receiving
treatment for their mental illness, they become physically ill because of the cold.

The psychiatric unit attached to Shumen General Hospital in the west of Bulgaria has
no heating, as there is not enough money. This unit is physically separated from the
main hospital, thus, as continues to be the custom in many countries of Central and
Eastern Europe, perpetuating the tradition of segregation of the mentally ill from the
rest of the population. I visited this unit and found one nurse in attendance. The unit
has approximately thirty beds, with four or five beds to a room, and one treatment room
that serves also as the staff room. The day room, which is used for relaxation therapy,
has damaged sofas, torn curtains and peeling paint and is hardly conducive to
relaxation. Patients rely on their families to bring them in extra clothing to combat the
cold and food, as the hospital diet is so poor. There are no sheets on the beds and
usually only one or two blankets. Blankets are washed twice a year when possible,
regardless of the number of patients using them. Patients go home at the weekends
and for public holidays where at all possible, in order to reduce expense. Patients and
staff use the toilets and washrooms in the unit alike. They are very basic and
unpleasant smelling. I spoke with three patients at the unit, all of whom praised the staff
for the care and kindness which they showed but criticised the lack of resources. The
nurse who showed us round the unit explained that she worked regular twelve-hour
shifts. Although initially reluctant to let us into the unit, as she said that she would get
into trouble for admitting strangers, the nurse eventually agreed to show us round as
we were accompanied by two psychiatrists from a nearby town. Like most of her
colleagues she has received no training although she would like to get some. What she
knows she has learnt on the job and by listening to the qualified staff.

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

There is a feeling that in smaller towns, free medication is not available as the
government restricts it to the larger towns. As a result out patients in rural areas often
have to buy their own medication, as the hospitals do not have enough money to
provide the medication free of charge. Patients collect their prescriptions from the
hospital clinic and then go to buy the medication before returning to the hospital for
treatment. Sometimes patients do not return because they cannot afford to buy the
medication. Medication is available but only if the individual can afford it. Often three
separate items are needed for treatment, costing a total of 132,000 leva that is the
equivalent to almost three months’ retirement pension.
 DYNAMICS WITHIN THE NGO SECTOR

The principal reason for my visit to Bulgaria was, as described in the Introduction, to
attempt to establish a clear view of the NGO sector. I was fortunate to have the
opportunity to meet with representatives from a number of NGOs - a total of ten in fact -
most of which are at different stages of development and activity. These meetings
provided me with a great deal of information about the internal structure of these
organisations, who some of the key players are, projects both real and proposed,
funding requirements, training needs and gaps in existing service provision. Details of
the various NGOs, including some proposals for partnership working with Penumbra
International, are provided as appendices. I also came away with the clear impression
that people are no longer willing to sit back and accept the current situation with regard
to mental health care. Furthermore I heard from a number of sources that there are
growing numbers of individuals and organisations, patients, service users and
professionals, who are becoming increasingly interested in actively influencing
legislation and policy development. There is also a heightened awareness of and
interest in the possibility of advocacy.

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

As mentioned earlier, Bulgaria is one of many countries to be currently experiencing

the traumas of post-communism. For so long the culture in Bulgaria has been to wait
for the state to provide whatever the individual was entitled to and then to accept the
inadequacies of that provision. There is no real experience of non-governmental
organisations, volunteer initiatives or user bodies. Amongst users of mental health
services, the culture is still predominantly to wait for assistance from psychiatrists or
other professionals rather than being able to act themselves to access possible
services. There is a lack of confidence and a lack of information, both of which are
aggravated by poor communication. In Shumen for example, out of 4,500 users of
psychiatric services, only 35 use the services provided by the locally based NGOs.
This is due partly to stigma and fear, partly to a lack of information and partly to lack of
resources for the NGOs. The NGO sector needs to educate people about what is
tantamount to a new concept, that of a non-governmental resource which is available to
everyone and which its users can directly influence. In order to achieve this change in
attitudes in a realistic way and within a realistic timescale, existing and emergent NGOs
acknowledge that they must work together on a programme of education. Further to this
need to educate the public, there is also a need to educate and communicate with the
government. Again there is recognition that NGOs need to work together in order to be
effective in raising their profile at state level and in informing the government about
their potential, their areas of expertise and their needs. A united network of NGOs
would certainly have more power as a possible consultative body with potential to
communicate and cooperate with the government and to influence legislation and
policy development in areas such as mental health.

Amongst the NGOs with which I met there was a very clear awareness of how little
experience there is in Bulgaria of NGO development in terms of organisational
administration and management. There is a strong feeling that, unless and until time
and energy are directed at NGO development, NGOs will continue to struggle to
sustain existing projects and initiatives. Training and experience are required in areas
such as organisational structure, strategic and action planning, budgeting, staff
training, fundraising, and networking. Again there is recognition that such training and
experience could and should be shared and disseminated amongst NGOs if there was
some forum for so doing. A network of NGOs could effectively pool resources and
enable member NGOs to gain experience from each other.

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

There is still enormous stigma in Bulgaria regarding mental illness. Most NGOs believe
and accept that they have a responsibility to work together to educate both the state
and the public in this area, by raising the profile of mental illness and mental health and
by disseminating information about mental health issues. Because their work is
essentially community based and carried out largely by volunteers, most NGOs are
aware that their workers and services can be more approachable and accessible than
those funded by the state. Given the existing culture in Bulgaria of trusting to the
experience and knowledge of recognised and familiar state funded professionals and
organisations, a number of NGOs recognise the importance of attracting interest and
involvement from professionals in the field. The idea is to attract support from
committed and well-minded professionals to establish the idea of community care and
of service provision by non-governmental organisations as both possible and viable. As
there is no history or experience in Bulgaria of carer or user groups, many NGOs
believe that involving such groups will only be achieved via the support of
professionals. At present it appears that there are a number of NGOs working on the
same agenda but with no clear process of cooperation. There is a need to establish
common and shared standards. To this end there was a meeting in January 1998,
between some mental health NGOs, to address the need for commonality.
To summarise, the NGO sector in Bulgaria is beginning to develop in certain areas
though it is still faced by a number of challenges and difficulties. There is growing
recognition within the sector of the role of NGOs in the Bulgaria of today and of the
future. There is also acceptance that, in order to fulfil this role, NGOs must develop as
effective organisations, learn to work cooperatively together, gain recognition at
government levels, educate the public as well as the state with regard to what the NGO
sector is, gain information and experience about external funding and establish regular
and clear ways of communicating with service users, carers, professionals and other
agencies. Changes are beginning to take place in terms of government recognition, as I
described in pages 11-12. Individual NGOs are beginning to develop links both with
other Bulgarian organisations and out with Bulgaria. Moves are being made slowly to
educate the public and to find information about organisational training. There are
some concerns however about the amount of training information with which NGOs are
almost being bombarded. Bulgarian NGOs are aware that they do not have the
experience to make an informed choice and some international organisations, including
Penumbra International, are concerned that the information that is most readily
available is not necessarily the best or the most appropriate.
With regard to working cooperatively, this is happening in some areas but it is
hampered by an atmosphere of jealousy and at times mistrust. The outline picture,
which was described to me by a number of NGO workers, tied in with the impression
that I myself formed of the dynamics amongst the existing mental health NGOs. There
are some clear issues, which need to be addressed and clarified, but which are at best
uncomfortable. I was given a great deal of information from a number of sources about
the current situation between NGOs. Although it is lengthy to wade through, it does
seem to be important in trying to establish a clear picture and with regard to
determining how and with whom an organisation like Penumbra International might
form a working partnership.

The main issue appears to be around a definite division into two camps. There is a
group of NGOs which, I was told, appears to be “controlled” by the eminent Bulgarian
psychiatrist Toma Tomov and which receives support from the Geneva Initiative on
Psychiatry because of the contact with Dr Tomov. I was very aware on arriving in
Bulgaria that my main contact, Alia Veder from the Neuroscience and Behaviour
Foundation, had already been openly critical of Toma Tomov and his” network” as she
called it. Peter Kampman had identified this during his brief visit to Bulgaria in May
1997 and had stated the importance of not allowing this particular view to influence our
perceptions. However this view was corroborated by a number of other individuals,
both in Sofia and out with the city. Those who spoke out were very clear that they could
do so without fear because they were not dependent on Dr Tomov for their jobs or for
funding for their NGOs. His critics claim that Toma Tomov does not like to be in the
limelight but that he wants to control the situation in Bulgaria and that he uses his
influence at the University and with the Geneva Initiative on Psychiatry to do so. The
feeling is that many of the younger and more recently qualified psychiatrists are
dependent on Dr Tomov’s approval and recommendation for employment, so they are
unlikely to risk disagreeing with him. It is, for the most part, these young psychiatrists
who are taking the initiative in seeing the need for community based projects and who
are therefore instrumental in establishing new mental health NGOs. In terms of
possible funding, there is further criticism that, for example, the Geneva Initiative on
Psychiatry only funds or supports funding proposals for projects which Toma Tomov
chooses.

The NGOs which are within Toma Tomov’s circle of influence include the Mental Health
Society of Sofia, the National Association of Mental Health and the proposed but as yet
unregistered Balkan Federation. There is criticism regarding money that the MHSS, in
partnership with the Geneva Initiative on Psychiatry, secured from the Ministry of
Foreign Affairs of the Netherlands in order to open a day care centre in Sofia. I was told
that Toma Tomov had supported the application and that the money had apparently
then gone into an account held by him. I am unsure as to the exact situation in this
instance although I did try, without success, to raise the issue with both Rumen Petrov,
the president of MHSS, and with Nicolai Butorin, the project manager for the Van Gogh
Centre. There does appear to be concern from some corners regarding the
transparency of accounting for funding received for specific projects. This is coloured
by the fact that some of the criticism came from NGOs in rural areas and there is
certainly a feeling that Sofia generally attracts more support, both local and
international, than other areas of Bulgaria.

Another key player within this group of NGOs, and connected in various ways with
Toma Tomov, is Rumen Ratchev. He was one of the founding members and the past
president of the MHSS and is the initiating force behind the National Association for
Mental Health and the Balkan Foundation for Mental Health. I am personally unclear as
to exactly what Rumen Ratchev does although he talks a great deal about proposals for
action. I heard some mixed reports about the viability of the National Association as a
truly national organisation, with doubts being expressed as to how representative it is
of NGOs at a national level. The National Association was founded in Plovdiv with,
according to Mr Ratchev, four founding members. However the MHSS, one of the
founding members, told me that there were only three member organisations, including
the MHSS. Boris Boyadjiev, the president of the Bulgarian Psychiatric Association, and
a member of the Board of Trustees of the National Association, expressed the opinion
that the National Association is not yet properly established, being only in the initial
stages of development as an NGO. He also felt that unless a user representative
organisation is directly involved in the National Association, it cannot develop as a part
of a modern society. There is, as yet, no user organisation involved in the National
Association although I understand that there has been some expression of interest from
such a group. According to the president of the MHSS a great deal of work still needs
to be done before the National Association can be influential. It has not yet succeeded
in acting as a coordinating force for mental health NGOs although Rumen Petrov feels
that Rumen Ratchev is doing some good work in his attempts to network with other
NGOs. There is a danger that Sofia is at times isolated other regions. Certainly when I
visited Targovishte and Shumen there seemed to be little known information about the
National Association and no one had heard of the Balkan Foundation. Even within
Sofia there appeared to be a lack of information about the existence of a National
Association; members of the Bulgarian Brief Therapists Society, which coordinates the
Day Centre Counselling Service in the premises of Sofia Hospital, had no knowledge of
the National Association.

Alia Veder maintains that the Balkan Foundation is just a name and that a number of
Balkan countries including Macedonia and Albania have not even been invited to join
the Foundation. I had occasion to speak briefly with the director of the Mental Health
Association of Dobritch, a Dr Evgheni Georgiev, who stated that he was shocked that
the president of the Balkan Foundation is a pharmaceutical company representative. I
did in fact meet Julian Zaimov who is the Business Unit Manager of the large
pharmaceutical company Janssen Cilag, with particular responsibility for psychiatry. He
was involved on behalf of Janssen Cilag in hosting a big conference and cocktail party
for psychiatric staff from the Shumen region. The conference was held in a hotel in
Shumen that is apparently expensive by Bulgarian standards and certainly charges
western prices at the bar. The president of the “Mental Equilibrium” Association in
Targovishte, Dr Emilia Dimitrova, who was invited to the conference and who
introduced me to Julian Zaimov, remarked on the lavish expense of such events in the
face of the state of the hospitals. Mr Zaimov took some considerable time to tell me
about his reasons for being involved with an NGO, despite his position as a drug
company representative. He feels that he can use his contacts and his position to the
benefit of the NGO and of mental health in general and that this should over-ride any
prejudice. Nonetheless such prejudice does exist and appears to be a definite
stumbling block for some people with regard to the credibility of an organisation such
as the Balkan Foundation.

The second camp of mental health NGOs support and speak favourably of the National
Network of the Bulgarian Mental Health, an organisation which was formed in 1997 by
the Neuroscience and Behaviour Foundation as a club of mental health NGOs
throughout Bulgaria, but which is not yet registered. The coordinator and president of
the Network is Alia Veder. At the time of my visit to Bulgaria the Network had fifteen
members of which at least six are user representative organisations. The existing
members are fairly well spread geographically, with seven organisations based outside
Sofia. Opinions about the work of the Network were all favourable although there was
recognition that there was a need for more formal organisation. Rumen Ratchev of
MHSS remarked that the Network was well based though still informal and in need of
clearer coordination. Representatives from three different NGOs with whom I spoke in
Shumen and Targovishte all expressed a desire to see the Network develop further.
They believe that the Network provides a good forum for the exchange of information
and for learning from the experience of other organisations. There was also very
positive feedback about an initial three-day training session that the Network had
organised in Varna in May 1997. Users as well as NGO workers attended this session.
There is clearly some considerable regret that there has not been sufficient funding to
hold another such event.

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

I am very aware that this section of my report is fairly damning with respect to Toma
Tomov and some of his contacts and colleagues. I have attempted throughout this
report only to reflect the information and opinions that were shared with me during my
visit and not to express my personal views. My impression of the tensions within the
existing mental health NGOs came from what was said directly to me and also from a
feeling that some things were being left deliberately unsaid. There were positive
comments made about the NBF and the Network by people who are closely involved
with Toma Tomov as well as by completely independent organisations. However when I
attempted to address the concerns that had been expressed to me about Dr Tomov
with some of the people most closely involved with his work in the NGO sector, I had a
definite feeling of avoidance. I do not feel qualified to make a judgement about this but I
am left with a feeling that support from Dr Tomov, as a psychiatrist with very real
influence and of international renown, is perhaps considered by some to be more
valuable at this stage in the development of mental health services in Bulgaria.
 NGO ACTIVITY IN THE FIELD OF MENTAL HEALTH

As I indicated in the Introduction to this report, there are currently a number of non-
governmental organisations actively engaged, sometimes against all odds, in providing
a variety of community based and free services to people with mental health problems.
I was impressed without exception by the creative energy and commitment of the
people involved in this work. Many of them have stressful and demanding full time jobs
on which they and their families depend financially; nearly all of them work as
volunteers in their roles as NGO staff; most of them willingly give up their evenings and
their weekends to be of service to their users. I met with the Executive Director of one
NGO based in Sofia which is embarking on a new project for the prevention of suicides
and which aims to offer, amongst other services, a crisis “hot-line”. This person
regularly, and to the obvious detriment of his health and personal relationships, spends
evenings and nights manning the telephone and attending to some of the necessary
administrative work for the NGO. His commitment, like that of some others whom I met,
is such that he cannot readily turn his back on the very clear and desperate needs of
the people around him, despite the cost to himself as a person. However without the
funding to provide salaries in addition to covering the costs of running projects, NGO
staff continue to struggle with this dilemma.
In terms of real action and projects which are already being implemented, I was again
impressed by the how much was being achieved in some areas with next to no
resources. The following section of this report gives specific details of the areas of
activity and interest of the NGOs with which I made contact while in Bulgaria. Some of
the projects were already in action when I visited in March 1998, while others were still
proposals. I include any recent and up-to-date information that I have received since
my visit.

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

Neuroscience and Behaviour Foundation (NBF)

This organisation was established as an NGO in Sofia in 1991. Its aims are “To
empower the work in the field of neuroscience and behavioural sciences through
citizens’ support and to contribute to the psychosocial culture of the society.” NBF has
a wide programme of activities focusing on research, education and training. Its
activities and areas of interest include the following: gypsies - life style and health;
psycho-educational programme for children with autism, their parents and carers;
training for volunteers for mental health projects; training of students as mental health
project volunteers; training in fundraising in the field of mental health; a national grant
programme for research projects in behavioural science; the contribution of NGOs in
Bulgaria to the issue of Human Rights and Mental Health; the production of a mental
health bulletin in both English and Bulgarian. NBF has also been closely involved with
and supportive of a number of translation and publication programmes of mental health
related documentation and literature. This work has been carried out in partnership with
the Bulgarian Psychiatric Association (NGO) and the National Centre for
Interdisciplinary Human Studies.

NBF is actively and continuously involved in fundraising both for its own projects and in
order to secure funds to support other NGOs with similar areas of interest. It strongly
supports the idea of cooperation and networking between NGOs and to this end has
been the creating force behind the establishment of the National Network of Bulgarian
Mental Health NGOs. The organisation is eager to make contact with international
agencies and is clearly successful in so doing. Having heard of Penumbra
International’s work in Romania, the Director of NBF invited Peter Kampman to visit
Bulgaria with a view to possibly forming a partnership to undertake a programme of
NGO development. As mentioned in the Introduction, this was our first contact with
Bulgaria.

A General Council manages this Foundation with responsibility to define and oversee
NBF policy and to approve the annual budget and the Executive Board. The Board is
elected by the Council and consists of the Chairman of the Board of Experts, the
Director and 4 other members. There is also a Control Board that, while elected by the
Council, has control over the Council’s decisions.

The National Association for Mental Health

This organisation was founded in Plovdiv with originally two members and an
expression of interest from a third organisation. The National Association has an
Executive Board compiled of a president, a vice-president, a secretary and a
treasurer/financial officer who is apparently the representative of one of the main trade
unions in Bulgaria and has personal contacts within government circles. There is also a
Board of nine Trustees. According to Rumen Ratchev who I understand is now the
vice-president (although when I met him in March 1998 he was the president), there
were approximately ten NGOs actively involved in the aims of the National Association
although they were not all members. All member NGOs must be registered, working in
the field of mental health, complying with the policies of the World Federation for
Mental Health and supportive of the aims and ideology of the Association. The
Association is aimed mainly at NGOs working in psychiatry rather than learning
disabilities, although both are possible. As a child psychologist, Rumen Ratchev is
keen to involve organisations working with children.

The Association aims to assist and support its member organisations, especially newly
established organisations both within Sofia and in other regions. Mr Ratchev is also the
initiator of the idea for a National Forum of NGOs. He hopes to be able to establish a
national forum for NGOs throughout Bulgaria to meet together in order to address the
need for cooperation between NGOs. His aim is that the National Association for
Mental Health will be one branch of this coalition of NGOs with a particular focus on
mental health. The intention is that a Consultative Council will be formed from the
National Forum of NGOs that will provide a line of communication between NGOs and
the government.
Currently the National Association needs funding for office space and at least one
salaried worker. It relies on the possibility of using the offices of other NGOs that
makes it difficult to develop as an organisation or to progress with some of the
initiatives that it has started. The lack of funding also prevents the Association from
implementing any specific projects. I was told that applications for funding have been
made to the Civil Society Development Association in Bulgaria and to the Democracy
Network Programme in the USA, although without success as yet. Mr Ratchev feels
that the most important first step is to buy a small flat in which to establish an office and
to begin working initially with volunteers. He would be interested in assistance from
Penumbra International to achieve this and also expressed a need for some methodical
assistance to develop both the National Association and the various projects. He
particularly specified training for NGOs that focused on developing human resources.
As yet there is no training available for leaders of NGOs although Mr Ratchev spoke of
an initiative with the New Bulgarian University that would focus on compiling a
programme for NGO leaders, based on western methods. Once trained, the students
could then become NGO leaders and train others, thus hopefully achieving fairly fast
results. Rumen Ratchev feels that an accredited training programme is necessary.

It would appear that all these initiatives are still at the proposal stage, due mainly to
lack of money to implement any of them. There was some mention made of the Family
Relation College in Sofia for which initial funding came from the Democracy Network
Programme in America. I am unclear as to exact relationship between the National
Association and the Family Relation College but the Association appears to be
involved in some way in securing funding for the College. I was invited to attend the
Family Relation College Conference on 3 March 1998 followed by a meeting of the
“ruling bodies” of the National Association in the evening. Unfortunately I was due to
leave Bulgaria on that day and could not therefore be present.

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

Bulgarian Psychiatric Association

The BPA was founded in 1992 and has both individual and group members, mainly
comprising psychiatrists and clinical psychologists. The organisation describes itself as
being “an observer, critic and advocate in the field of mental health in the country
(Bulgaria)” and its aims include attempting to carry out legislative reform, the active
promotion of mental health and the improvement of mental health care. The position of
the BPA on reform can be summarised in a vow for development as opposed to
survival. The BPA believes that psychiatry needs to move away from its traditionally
held image of control over the mental life of individuals and to become more responsive
and accessible and therefore better able to address the changes taking place in the
lives of the Bulgarian people, especially during the current period of transition.

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

Boris Boyadjiev, a Control Commission and an Ethical Committee all of which are
elected by a General Assembly, administers the BPA. It is involved, amongst other
things, in the organising of an annual conference, in various editing and publishing
programmes of translated books and documents in conjunction with the National Centre
for Interdisciplinary Human Studies and a number of other organisations and in actively
addressing the need for professional training in psychiatric nursing. The BPA welcomes
cooperation from and with other organisations.

Mental Health Society of Sofia (MHSS)

The Mental Health Society of Sofia has recently adopted a one-year presidency system
with the vice-president being the president elect for the following year. I met Rumen
Petrov, the current president at the time of my visit, along with some of the volunteer
project workers and the part-time administrator. There is also a part-time accountant. At
present the society consists of about 8 project workers (young psychiatrists and clinical
psychologists) who are involved in running psychodrama groups, psychoanalysis
groups and who undertake assessments. The society hopes, if they can secure the
necessary funding, to be able to appoint a social worker and some psychiatric nurses
on a part-time basis, possibly students. Social workers would be useful in assisting with
a proposed social club.

At present the society has some 60 - 70 members. The project workers are volunteers
although they can receive some small payments from the projects to cover expenses.
The president and other committee members are not paid. Since nearly all of the
workers have salaried jobs they have little time to commit to the work of the society.
MHSS has no independent office from which to coordinate its work and is aware of
problems with regard to effective communication and information sharing. It also feels
that it has a need, as an organisation, for appropriate consultancy assistance in order
to develop effectively.

MHSS was officially established in 1994 although its initial project work began in 1992
with the creation of a users’ social club. The Social Club is a self-help group meets
regularly at a small flat in Sofia with a usual attendance of 12 to 15 members. The Club
provides a forum for group discussions and certainly appears to be organised and run
mainly by the users, with minimal input from the project workers other than for
administrative reasons. MHSS is also involved in organising national conferences that
are held in connection with World Health Day. Other activities include projects in the
field of mental health research and care. One such project is the College for Family
Relations that has been funded by the USA based Democracy Network Programme
and is supported by the Development of Civil Society Foundation in Sofia. This project
provides an educational programme for families and relatives of users of mental health
services.

A new project called the Day-Care Centre Vincent Van Gogh has recently started in
Sofia and is being funded by the Ministry of Foreign Affairs in the Netherlands. This is a
two-year project that MHSS is running in collaboration with the Geneva Initiative on
Psychiatry. The project aims to design and implement a community based psychosocial
care programme directed at “promoting social adaptation and integration of people with
persistent psychiatric problems”. The programme has been adapted from a programme
run by the University of California, involving structured modules that focus on training in
social and community living skills such as basic conversation skills. The project
Manager, Nikolai Butorin, has personal experience of working with these modules that
he believes stimulate people to be more interactive in society and the community. This
project is also intended to act as a pilot for other such centres. MHSS has a long-term
vision to create good examples of well functioning community based projects in Sofia,
which can then be used elsewhere. The intention is that the Van Gogh Centre will
provide a model of a day care centre that can be developed to be used throughout
Bulgaria. MHSS hopes that, as such centres are established and develop in other
areas, students and mental health professionals who are interested in this type of
community-based work will come to look around and to receive training. MHSS has
apparently met with the Ministry of Health in order to promote this model of service as a
viable way forward.

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

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

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

Over the past couple of years, MHSS feels that it has been finding its identity and that it
is gravitating towards community care. The main concerns which members of the
organisation expressed during my visit were 1) how to attract people who are eager
enough, brave enough and trained enough to be a part of the community based work
with which MHSS is involved, especially in the face of existing stigma, 2) how to secure
sufficient funding to develop the work of the organisation when the government gives
no such support. The programme which MHSS has drafted for the future includes
providing education and information about mental health issues, providing support for
young professionals who are caught between the expectations and demands of
traditional psychiatry and the growing voice of users, sharing its experience of project
implementation and disseminating examples of good practice.

Trust Line

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

Miloserdie Foundation

This NGO is a small organisation that runs a hospice and provides support services
such as meals-on-wheels for the terminally ill and for other groups of vulnerable people
including the elderly and those with mental health difficulties. Miloserdie Foundation is
linked with the Central and Eastern European Network and has received some EU
funding. The Foundation has some contact with Help Age International.
Bulgarian Brief Therapists’ Society

This NGO was established and registered in 1994. I am unclear as to the specific aims
of this organisation as I am still waiting for more information. According to Boyan
Strahilov, brief therapy is an approach that is very appropriate to Bulgaria as Bulgarian
society and culture is generally permissive with very few taboos. The therapy focuses
on decision making and coping strategies, using the power of language. It is based on
system thinking and problem solving and developed in Europe and the States in the
1970s.

Training in psychotherapy is limited and incomplete in Bulgaria with very few

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

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

This NGO has been active in the Shumen region since 1996. Its members include ex-
patients and users of mental health services, families of users, specialists, psychiatrists
and volunteers. The Club provides a meeting place for its members and acts as a
network for support. The NGO aims to contribute to the re-socialisation of ex-patients
and users of mental health services and to promote mental health as a basic need.
Along with disseminating information about mental health issues, the Club wishes to
work towards ensuring that appropriate medication and treatment are regularly and
readily available for patients and users and that there is some financial support for their
daily needs.

The Ex-Patients’ Club has no real funding other than a government grant of £10 per
year, which is the equivalent of the registration fee. The Club has no resources other
than the use of a house which is provided free of charge by the municipality. Equally
there is no technical equipment available. All the workers with the NGO are volunteers.
Employment opportunities for users are not normal practice in Bulgaria, except
occasionally within hospitals. Thus there are no income possibilities in this area for
NGOs. There is clear recognition amongst the members of this Club of the need to
develop as an established NGO. To this end members have already participated in an
initial training programme run by the National Network of Bulgarian Mental Health
NGOs and they spoke very positively about the programme and its benefits. The
training needs which Drs Penkova and Nikolova expressed during our meeting focus
on the following areas:

• Basic administrative and management training. The NGO has no clear

administrative structure as yet and recognises the importance and need of
acquiring such know how as soon as possible. Without this there is little
opportunity of developing as an effective NGO. Once established in this area,
the Club would like to contact the local media in order to advertise its services.
Skills in project development and compiling appropriate programmes are also
required along with training in how to make most effective use of existing and
new communication networks.

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

The Ex-Patients’ Club is interested in exploring the possibilities of tool kits and
information packs as a means of developing as an organisation. There is a strong
belief within this group that NGOs need to develop as effective organisations in the first
instance and then work together to educate people about the work of the NGO sector
as a whole and to address the issue of stigma by raising the profile of mental health
through information and education. There is also an active desire to include users in
training initiatives. Apparently 7 users from Shumen attended the training session in
Varna (see page 20) and returned feeling empowered and informed about the
possibilities of NGO activity. Unfortunately there are usually insufficient resources for
more than 2 or 3 representatives to attend training sessions.

Balkan Federation for Mental Health

Despite meeting with Julian Zaimov who is on the Executive Committee of the
Federation, I could not find out any information about this organisation. It appears to be
just a name at this stage.
Mental Health Society of Targovishte

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

I met with some members of this Society and was impressed by their clarity of direction
and by the interest that they expressed in their rights as service users to influence
legislation and policy. Advocacy and accurate representation are high on their list of
priorities. Once again funding is an important issue and many views were shared
regarding the lack of employment opportunities for service users in the Bulgaria of
today. Members expressed ideas for possible income generating projects but without
the necessary start-up funding the projects cannot be realised. I received requests for
assistance from Penumbra International in securing funding for such projects. Also
there were requests for assistance with training in organisational development and in
how to market products, in the event of the income generating projects being realised.

Other proposed projects and areas of activity include the development of social policy
relating to Advocacy and Human Rights issues for people with mental health problems;
work with women and children who are the victims of violence; research into mental
illness in a trans-cultural context; work with AIDS sufferers and drug addiction including
a programme for installing blood-testing equipment in local areas; working in
partnership with the “Mental Equilibrium” Association to address the issue of mental
health and human rights in the Targovishte area.

“Mental Equilibrium” Association (Targovishte)

This organisation consists mainly of professionals (psychiatrist, social workers

psychologists and others) from the town of Targovishte and its surrounding area who
are involved in, or have an interest in, the field of mental health. The Association has
close links with the Mental Health Society of Targovishte and shares some of its aims.
Its main objectives are to contribute to the improvement of mental health services in the
region; to assist its members in gaining better medical qualifications, experience and
training; to research and provide medical evidence of the need for specific projects.
The organisation’s programme of activities includes a project to initiate change in the
structure of psychiatric services in the region; the promotion of mental health through
cooperation with the media; research into the area of genetics and mental illness; work
with children and adolescents at risk particularly from drug addiction; the creation of a
data-base for information on mental health issues; the development of partnerships
with other organisations, local, national and international. The Association already has
active links with the Neuroscience and Behaviour Foundation and the Mental health
Society of Targovishte. Members of this organisation also work together in small
groups of 3 or 4 to visit outlying areas in order to provide a community based follow-up
care service. They focus on assessing difficulties, checking medication, providing
information etc.

Members of “Mental Equilibrium” Association acquired funding from the Bulgarian

government to establish a Drug Abuse Centre that provides, amongst other services,
an outreach programme which moves round the region. Courses are available on drug
prevention, targeted particularly at children and adolescents. The Clinic is working in
partnership with the National Drug Centre in an attempt to manage the drug problem in
schools. A training course is being run this year to enable teachers to learn how to
speak with pupils about drug related issues. The Clinic is run from premises that are
separate from the hospital. There is a 24-hour help line with an answer machine that is
checked every 4 hours. Four volunteer workers man the help line. In addition the
project is involved in compiling and distributing leaflets.

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

LIFE Foundation (Targovishte)

LIFE Foundation was established in 1996 working in the areas of health services,
education and social welfare. It is dedicated to the improvement of the state of health
care and disease prevention in the Targovishte region by developing educational and
medicinal programmes and by assisting the regional hospitals through donations of
medical equipment and medicines. It also organizes conferences and seminars aimed
at furthering the learning and experience of local professionals and at improving the
health culture of young people in the area. LIFE Foundation has for example published
some educational leaflets on the issues of safe sex and AIDS prevention aimed
primarily at young people.
The foundation is staffed by 7 volunteers and greatly values the possibility of close
cooperation with similar organisations both in Bulgaria and elsewhere.
National Network of Bulgarian Mental Health NGOs

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

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

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

“Budnina” Foundation

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

One of the projects that the “Budnina” Foundation undertook recently, together with the
New Bulgarian University, involved the production of a documentary film entitled
“Suicide”. The organisation is currently trying to secure funding for a project that will
provide a “Protected Social Network for People with Suicidal Behaviour”. Although the
project will initially be based in Sofia, the aim is to ensure that appropriate support and
crisis intervention are accessible across the country by the creation of an efficient
network. In addition to providing support and information to people in crisis situations
and their families, the project aims to inform and educate society with regard to the
tragedy of suicide and to form active and productive relations with other agencies that
have contact with people at risk.
The Foundation has a Management Board with a Chair and 3 Board Members, 1 of
whom is the Executive Director. A team of 10 volunteers carries out the activities of the
Foundation. As with many other Bulgarian NGOs, the “Budnina” Foundation recognises
that it needs training in a number of areas in order to develop as an effective
organisation. The areas which the Foundation have specified include: management,
budgeting and accountancy, fundraising, networking and forming partnerships, IT and
communication skills.
 OTHER AGENCIES

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

The National Centre focuses its activities around areas such as patients’ human rights,
mental health legislation, assessment of care needs, development of community mental
health services, users’ involvement in the planning and monitoring of mental health
policy and service, the integration of mental health and primary health care etc. Its
main functions are to initiate, organise and coordinate the following activities:

• The research of human behaviour in the field of neuroscience, social and

developmental sciences, mental health and health behaviour
• The collection and dissemination of information and transfer of know-how into
mental health practice
• The training of professionals in the field of public health, psychiatry, education
and other related professions
• Surveys, analyses, expertise and programmes for the formulation and realisation
of national mental health policies

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

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

I also learnt about the work of the Department of Medical Ecology and Nutrition at
the Centre of Hygiene in Sofia. Some of the Heads of the Department, whose work
focuses mainly on the areas of child hygiene and nutrition, expressed a wish to meet
with me in order to discuss work which they are currently doing in the area of exploring
the links between the physical and the psychosocial needs of children at risk. Staff
working in the areas of child hygiene and nutrition have joined forces in an attempt to
best address the needs of children at risk. Over the past 4 years, research has taken
place on a national basis into the physical and psychosocial needs of children in social
homes. There are apparently over 20,000 children living in social homes in Bulgaria, a
figure which staff at the Centre of Hygiene find very high compared with the total
population. Any nation wide investigation is difficult to undertake as the children are of
varying ages, ranging from 0 to 18 years, and live in different administrative regions;
there are regional differences that must also be taken into account.

Children who live in care from the age of 0 to 3 years should be placed in homes for
mothers and children but are, in reality, usually put into orphanages under the
management of the Ministry of Health. From the age of 3 to 18 the children are moved
to other homes that are the responsibility of the Ministry of Science and Education. A
group of children with perceived learning difficulties (although no proper needs
assessment is carried out) are however sent to homes managed by the Ministry of
Social Welfare. A further group, often with chronic or permanent physical difficulties
such as asthma, blindness or deafness, live in recreational schools under the
jurisdiction of the Ministries of Health and of Education. Also there are residential
schools that come under the name “Education by work”, for children who have
committed crimes. The Ministries of Internal Affairs (police) and of Education have joint
responsibility for these establishments. Understandably there are difficulties in trying
to ensure some level of cooperation and collaboration between the various Ministries,
and in trying to form a coherent policy for the appropriate care of children at risk.

There are serious problems for children after they leave the comparative shelter of the
various institutions mentioned above, as many of them have no homes or families to go
to and few skills to assist them in adapting to adult life on their own. Given the
economic situation in Bulgaria, there is no real financial aid for these youngsters and
there is stiff competition for jobs. In an attempt to address this problem, several
psychosocial programmes have recently been started for children in various
institutions, focusing on areas such as basic academic achievement, social skills and
regular nutrition. The staffs with whom I met at the Centre of Hygiene, who are involved
in these programmes, provided me with a list of their specific areas of concern and
made various requests for information and expertise to assist them in improving their
current service. They wish to find more effective ways of working by learning from the
experience of others working in the same field. Good practice documents have been
requested on working with children at risk.
 IN CONCLUSION

What struck me most out of the many experiences of my first visit to Bulgaria, and the
memory which remains strongest nine months on, is to do with the remarkable and
inspiring sense of there being a job to do and that now is the time to do it. Of course
there is despondency and frustration and at times a feeling of wanting to roll over and
accept whatever happens, in the hope that it might just be an improvement on the
reality of the present situation. Given the recent years of turmoil and change, this state
of exhaustion is easily understood. How do people, after years of being told how and
almost when to live, suddenly find or create the resources to start living on their own
strength? And yet, certainly amongst the people with whom I met, there is an invasive
feeling that the past is past and there are lessons to be learned and experiences to be
used which can help in building a future which is worth living. As I said earlier in the
report, with specific reference to the state of mental health services, I was impressed by
the growing awareness amongst both service users and some professionals of issues
such as the need for advocacy and the importance of the individual to be involved in
determining his\her own future. I was also struck by the fact that, when asked how an
organisation like InterMinds might be of use or of help to existing and emergent NGOs,
nearly all the replies focused on requests for information, assistance with training and
NGO development, followed by requests for funding. Certainly most of the
organisations that I visited have few resources if any. Most of the people involved in the
NGO sector work as volunteers and rely on the goodwill of their employers or the local
municipal authorities for basics like meeting premises or office equipment. However
despite this, there is a realistic recognition of the importance of establishing NGOs as
effective organisations that have the inbuilt skills and resources to support, sustain and
carry out their aims.

There is clearly an enormous amount of work to be done in Bulgaria in order to

establish a system of care and service provision which adequately and appropriately
answers the needs of people with mental health problems. In the first instance mental
health must appear on the health agenda with the forming of specific mental health
legislation and policies which clearly reflect today’s world. This is beginning to happen
under the existing government and will be further supported by the appointment of Dr
Toma Tomov as President of the Association of Mental Health Reformers in Eastern
Europe, to be based in Sofia. The voices of the voluntary sector are beginning to be
heard through the creation of posts such as that of the Chief Advisor to the Minister of
Social Affairs (see page 11) and the recognition that groups such as a Consultative
Council of NGOs have a valid and important part to play in accurately reflecting the
needs of service users. There is still considerable reluctance on the part of
psychiatrists from the more traditional schools; to support the concept of community
based care. This, along with continuing stigma around the whole issue of mental illness
and lack of information about what NGOs are, makes the task even more difficult for
local NGOs eager to establish projects in the community. Concerned parties have
identified the urgent need for efforts to be directed towards raising the profile of mental
illness and towards mental health promotion. The culture of compliance and
acceptance that is prevalent throughout Bulgarian society needs to be broken in order
that mental health legislation and practice might change. Also people need to be
educated about the potential of non-governmental organisations.

With regard to the development of community based projects and services specifically
targeted towards people with mental health difficulties, there are a number of initiatives
already in place, some of which are described in the section entitled “NGO Activity in
the Field of Mental Health”. However, for the most part, they lack the backing of a well-
established organisation with the resources and know how to adequately support and
develop such projects. There is a clear role here for an organisation like Penumbra
International, which has the experience and expertise to assist local groups to develop
as effective NGOs. Penumbra International can provide specialised staff and
organisational training to support such development. Also, in partnership with local
mental health organisations, Penumbra International has the skills and experience to
assist such organisations to establish, develop and sustain community based projects
which will provide appropriate and accessible services in answer to previously
assessed and identified needs.

Furthermore, and in response to a specific request for assistance in this area,

Penumbra International is keen to play a part in developing a strong and effective
national network of mental health NGOs. Such a group has already been formed and
has been enthusiastically received by its members. There is clear recognition of the
value and importance of a unified and cooperative network, which can provide an
appropriate forum for discussion, support and skills exchanges between NGOs working
in the same field. There is also considerable interest in the possibilities of such a
network gaining recognition and acceptance as a truly national organisation with an
important and valid role to play in coordinating and representing the voice of its
members and most especially of its user members.

To summarise, a start has been made. In certain areas of the population there is a
growing awareness, both that the existing situation with regard to mental health can no
longer be tolerated and that the task ahead is enormous, involving cultural as well as
legislative, economic and professional issues; there is a thirst for information and a
definite and determined feeling amongst informed groups that the time is right for
action. The message that I received throughout my visit was a clear request for
assistance from international organisations, experienced in mental health issues and
willing to work in partnership with local organisations. There is acknowledgment now
that the state has not, in the past, and cannot, in the future, provide all the answers.
One psychiatrist whom I met in Shumen, told me that she believed that she had a clear
position, both in her professional capacity and as a social being, to provide (“patients”)
people with mental health difficulties with the care and support which they need. She
underlined her belief that society, as a whole must share this responsibility with the
state. I found this statement particularly encouraging, considering both Bulgaria’s
cultural and historical response to mental illness and its recent experience of
communist rule.
 APPENDIX I
Public Health Act (1973)
Article 2

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

2. The government takes comprehensive measures for preserving and restoring

the health of citizens and provides free, accessible and qualified medical care,
setting up the necessary network of public health establishments.

4. Besides of public health institutions, medical care can be given in health

institutions of physical and legal persons, as well as in clinics of medical
specialists on private practice.

Article 25a

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

Article 36

3. Liable to compulsory treatment in public health establishments are patients with

mental disorders, specified in the Application Rules of this Act, after their being
examined by a commission of specialists.

4. All admissions of patients under the above paragraph are carried out only upon
a Local Court’s decision, following the procedure specified in Articles 59 (page
2), 61 (pages 1,3,4) and 61 (page 1) of this Act. When the patient’s condition
makes impossible his appearance in court, he is visited and heard out in the
hospital.

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

6. The compulsory treatment in a hospital is discontinued when it is deemed no

more necessary. In any case if the treatment is continued the court should
reconsider the case every year with regard its continuation or discontinuation.
Article 59(?)

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

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

Article 60

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

Article 61

1. The Local Attorney makes a proposal based on a check-up and a medical

expert’s conclusion.

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

Article 62

1. Within a couple of weeks after the proposal has been deposited the case is
considered by the Court in an open session in the presence of the Attorney and
the person whose compulsory treatment has been demanded.

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

Article 63

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

2. When the Attorney’s proposal is deemed valid, the Court specifies the
specialised health establishment and the period of the compulsory treatment.
The period may not exceed one year.

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

4. The effected decision is executed by the health institution to whom the police
may give assistance, if needed.
Article 64

1. Summoned by an Attorney’s proposal based on a medical expert’s conclusion,

the Court may discontinue the compulsory treatment in an open session.

2. When the person is not cured in the decided period of time the Court,
summoned by an Attorney’s proposal and on the basis of a medical expert’s
conclusion may enact a new decision for compulsory treatment, following the
procedure mentioned.

Article 65

1. The compulsory treatment is carried out in specialised health establishments,

organised by the Ministry of public Health in co-operation with the People’s
Councils.

2. The compulsory treatment is combined with work therapy in workshops and

farms, founded at the specialised health establishments for that purpose. The
patients’ labour is paid accordingly.

Article 66

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

Article 67

The compulsory treatment having been finished, the People’s Councils at the
residence and at the workplace of the patient, at a request made by the health
establishment take steps to arrange his work and living conditions and to protect
him from repeating the alcohol or drug abuse.
 APPENDIX II
Rules for Application of the public Health Act (1977)
Article 67

Liable to admission for obligatory treatment under the terms or article 36 (p 3) of

the PHA are individuals suffering from schizophrenia, cyclophrenia, epilepsy,
senile, presenile, traumatic, vascular and organic mental disorders; infectious,
somatogenic, psychogenic and toxic psychoses, oligophrenia and severe
personality disorders, who, due to their illness, may commit a serious legal
offense or are dangerous for their relatives or for the community or seriously
endanger their own health.

Article 68

1. The Attorney may be notified by state or social organisations, health

establishments, relatives and other citizens of the need to proceed for an
obligatory treatment of mentally ill individuals.

2. Signals and proposals from the health establishments should be accompanied

by medical documentation, motivating the need for treatment.

Article 69

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

Article 70

1. In cases when the condition of the mentally ill makes immediate measures
necessary and he has been temporarily admitted following the procedure of
article 36 (p 5) of PHA the Head of the establishment should inform the Local
Attorney within 24 hours, following admission.

2. If the Attorney refuses to make a proposal in the cases, specified by article 69

and by the above paragraph, the health establishment should release the patient
immediately.

Article 71

The Court’s decision for obligatory admission is executed by the appropriate

psycho-neurologic dispensary at the patient’s residence and in cases of
disobedience - with the cooperation of the Ministry of Home Affairs’
representatives.

Article 72

The psychiatric establishment informs the patient’s relatives immediately after

 his being admitted for obligatory treatment.

Article 73

1. When the obligatory treatment is deemed no more necessary the Head of

psychiatric establishment sends a proposal for its discontinuation to the Local
Attorney, accompanied by the appropriate medical expert’s report.

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

3. If the Court decides to discontinue the compulsory treatment, the health

establishment should release the admitted immediately.

Part 5: Work Therapy

Article 98

Work therapy farms and workshops may be organised at the health

establishments for Work therapy of both in-patients and out-patients to be
carried out.

Article 99

1. The Work therapy farms and workshops are either financed by the state or
financially autonomous, but not incorporated.

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

Article 101

All good produced and services performed by the Work therapy farms and
workshops are tax-free.

Article 102

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

Article 103
 For work and treatment at the Work therapy farms and workshops at the psycho-
neurological establishments, disabled patients of 2nd and 3rd groups may be
accepted. Mentally disabled patients of 3rd group may be employed there as
regular workers too.

Article 104

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

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

Article 105

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

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

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

encouragement, too, for their work participation.

Article 109

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

Article 110

The Minister of Public Health, The Chairman of the Bulgarian Trade Unions’
Central Council and the Minister of Labour and Social Welfare issue
Regulations for the application of this part.
 APPENDIX III
Constitution of Republic of Bulgaria (1991)
Article 5

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

4. The international contracts ratified in constitutional way, published and come

into force for Republic of Bulgaria, are a part of internal law of the country. They
have priority over such rules and regulations of internal legislation which
contradict them.

Article 28

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

crime.

Article 29

1. Nobody can be subjected to torture, to cruel, inhuman or humiliating treatment,

neither to a forced assimilation.

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

written consent.

Article 30

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

Article 32

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

2. Nobody can be photographed, filmed, registered or subjected to other similar

actions without his consent or in spite of his expressed disagreement, except in
cases foreseen provided by the law.

Article 34

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

sacred.

2. Exceptions to this rule are admitted with permission of the judicial authorities,
when it is necessary to reveal or avert severe crimes.
Article 42

1. Citizens aged over 18, excluding those considered legally completely incapable
by court and persons convicted to serve a prison sentence, have the right to
 vote for government and local authorities and to take part in referendums.

Article 48

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

4. Nobody can be forced to do compulsory work.

Article 51

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

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

Article 52

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

4. Nobody can be forced to compulsory treatment or sanity measures, except in

cases foreseen by the law.

Article 56

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

Article 57

1. The basic rights of the citizen are irrevocable.

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

3. On declaring a war, a military or other extraordinary situation, temporarily can be

limited by a law the exercise of some rights of the citizens, excluding the
provisions under Articles, 28, 29, 31 (1,2,3), 32 (1) and 37.
 APPENDIX IV
Schedule of Meetings and Visits

Tuesday 24.02.98

Evening Meeting with Amelia Nikolova, President of the Neuroscience and

Behaviour Research Foundation and Alia Veder, Director of the NBF.

Wednesday 25.02.98

AM Meeting with Rumen Ratchev from the proposed National Mental

Health Association. Also present was his Secretary and Public Relations
Officer

PM Meeting with Boris Boyadjiev, President of the Bulgarian Psychiatric

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

PM Video Presentation and Discussion with Dimiter Stamenov and 2

psychology student volunteers from the Mental Health Society of Sofia.
This meeting was also attended by a group of volunteer psychiatrists and
some student volunteers who run an emergency ‘phone-in service in Sofia
called Trust Line. In addition I met Katarina Dimova who works with the
Miloserdie Foundation.

Thursday 26.02.98

AM Meeting with Boyan Strahilov who is a member of the Bulgarian Brief

Therapists’ Society and is involved with the running of a Day Centre
Service at Sofia Hospital along with Georgi Nestorov Arsenov and
Diana Velkova.

PM Meeting with various Heads of Department from the Centre of Hygiene in

Sofia, including Associate Professors Vassil Pisev, Donka Baykova and
Blagoy Yordanov. The Departments involved in this meeting are
concerned with children at risk and their work concentrates particularly on
the areas of Child Hygiene and Nutrition. Also present at this meeting
were Amelia Nikolova and Alia Veder.

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

Friday 27.02.98
AM Meeting with members of the Mental Health Society of Sofia. We met
with Rumen Petrov, President of the MHSS and other members of
MHSS.

PM Travelled to Targovishte in the west of Bulgaria. Ongoing meetings with

Emilia Dimitrova, a psychiatrist at Targovishte hospital and President of
the “Mental Equilibrium” Association. I also met regularly with
Vesselka Vassileva, a child psychiatrist and President of the Mental
Health Society of Targovishte.

Saturday 28.02.98

AM Meeting with some delegates attending a conference in Shumen, hosted

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

PM Visit of Psychiatric Unit on the outskirts of Shumen, attached to Shumen

Hospital. Met with the duty-nurse and with some patients.

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

Sunday 01.03.98

AM Further meetings with staff from Targovishte Hospital including Dr Ivan

Tianev who is involved with an organisation called the Life Foundation,
in Targovishte.

PM Returned to Sofia.

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

Monday 02.03.98
AM Follow up meeting with Boris Boyadjiev and Vesselka Christova from
the Bulgarian Psychiatric Association

Tuesday 03.03.98
AM Meeting with the Chief Advisor to the Minister of Social Affairs (with
particular responsibility for NGOs), Mario Sarbinov

PM Meeting with Todor Mindilikov the Executive Director of the Budnina

Foundation”.
 APPENDIX V
References

Bulgaria Business Guide - Foreign Investment Agency

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

EURO WHO (European Region) Report

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

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

“Voluntariness: Inconsistency in Law and Psychiatric Practice in Bulgaria” - paper

presentation by Boris Boyadjiev World Congress of Psychiatry, Madrid, 1996

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

Public Health Act (1973) of the Republic of Bulgaria

Constitution of the Republic of Bulgaria (1991)

Penal Code of the Republic of Bulgaria (1968)

Bulgarian Ministry of Public Health, State Gazette no 58 (July 1981): Instruction no 1

on the Duties of Health Authorities Regarding Compulsory Admission to Psychiatric
Hospitals