State Psychiatric Hospitals a) Funding and human resources The NPM found once again serious differences in the funding and remuneration of medical specialists at SPHs and MHCs. MHCs are funded in accordance with the Methodology for subsidies for MoH medical establishments based on treated patients, whereas state psychiatric hospitals are funded on the basis of historical budget. The NPM should note that since 2018 there has been an increase in the Salary Fund of all hospitals. In Karlukovo SPH the salary of nurses starts from BGN 940, for janitors from BGN 625, and for doctors from BGN 1,200. On the other hand, the financial resources for capital expenditure at hospitals do not cover the requests submitted to the MoH. Such an example is Kardzhali SPH where the director requested in 2019 financial resources for “Partial repair of internal sewerage, a new external drainage and supporting walls for the maintenance of the site” but no such funds were granted. The medical establishment applied for funding under the “Beautiful Bulgaria” Project 2020 but in order for the project to be implemented, it needs co-funding from the ministry in the amount of 50% of the funds. In this regard, the NPM made recommendation to the MoH to co-finance Kardzhali SPH. The average cost of food per day in 2018 for Kardzhali SPH is BGN 2.05 and for Karlukovo SPH is BGN 1.92, which is little below the average for the country for that type of establishments (BGN 2.51). In Kardzhali SPH, the average cost of medicines per day in 2018 is BGN 0.97, which is below the average for the country for that type of establishments (BGN 1.66). In this connection the NPM considers that the budget of the Maintenance Fund for the state psychiatric hospitals should be increased. For a consecutive year the NPM found chronic deficiency of medical and non-medical specialists in the outpatient mental care medical establishments, which affects the quality of medical services. To cover the 24-hour doctor schedules, doctors under contracts are used. The inspections in 2019 showed that Kardzhali SPH has 4 vacant doctor positions and doctors from Kardzhali EMCC are used to ensure the 24-hour medical doctor care. In Karlukovo SPH there are two vacant positions: for a doctor head of ward and for master pharmacist. b) Location and facilities In most cases SPHs are located outside settlements, isolated, with bad road infrastructure, which is in conflict with the requirement of the Psychiatry medical standard (Karlukovo SPH, State Psychiatric Hospital in Karvuna, Balchik Municiplaity, Novi Iskar SPH). Few of the state psychiatric hospitals are located in cities with possibilities for provision of integrated medical and social services. Such is the case of Kardzhali SPH which is located in the city of Kardzhali and in proximity with the Multi-Profile Hospital for Active Treatment “Atanas Dyakovski”, which has a binding contract for joint medical services. Another good example is Pazardzhik SPH which is in close proximity with Pazardzhik Multi-Profile Hospital for Active Treatment. In 2019, the NPM again established unsatisfactory conditions in the facilities of the state psychiatric hospitals, which do not meet the modern requirements for medical establishment. During the inspection of Karlukovo SPH it was found that three of the wards are located in an old and dilapidated three-storey building. Access to it is by means of stairs which are unstable and do not have any handrails to support the patients and staff. The NPM recommends an urgent repair of the entrance stairs of the hospital building and installation of 34