Bulgaria took steps to reform its health care sector in 2000. This led to changes such as introducing the general practitioner (GP) or family doctor as a gatekeeper to specialized health services. All inhabitants are now required to register with a GP in order to gain access to health care. It also marked the end of financing health care from the general state budget.

Today the costs are carried by employer and employee contributions. Sexually transmitted infections (STIs) are a health care problem in the country. The management of STIs is unregulated and unstandardized. As a result, several treatment protocols are used leading to unnecessary laboratory tests and, in some cases, overmedication with the resulting risk of developing resistance to drugs.

In addition, people living with syphillis face stigmatization and discrimination. However, the situation is slowly improving. After efforts by MSF and a round table discussion involving all important health sector actors (including MSF) took place in May 2004, a working group was established. The group's main task is to develop the themes discussed at the roundtable meeting in order to propose recommendations on the diagnosis, treatment and testing of STIs.

The group also aims to have national health insurance funds cover or reimburse the drugs and laboratory tests for STIs. Since January 2000, MSF runs the diagnostic, treatment and prevention center (center for sexual health) located in a university hospital in the capital, Sofia.

The center's staff provides treatment for STIs and care to help prevent HIV/AIDS. Needed medicines are given out free of charge to insure that the very poor have access to them — a group considered most vulnerable for STIs and HIV. The center is also increasing its health education activities in schools. Nurses from the center are often invited to participate in educational sessions at schools in Sofia and in the countryside.

MSF began making rounds with a mobile clinic in September/October 2003 in order to reach marginalized inhabitants in Sofia who do not visit the center on their own initiative. The mobile clinic staff comprises one nurse, one doctor, one psychologist and a driver. Every week the clinic visits four different locations within metropolitan Sofia.

The team offers immediate treatment of acute STIs, information and education on safe sex practices, information on STI prevention, voluntary HIV testing and counselling. Most of the mobile clinics patients are commercial sex workers and intravenous drug users.

The sexual health center's staff have formed an association under Bulgarian law so that they can take over the center's activities when MSF ends its involvement in early 2005.

The center's STI program has also been replicated in the city of Plovdiv. A clinic in Plovdiv University Hospital has been rehabilitated and Bulgarian medical and paramedical personnel now carry out activities related to treatment and prevention of STIs. While the staff's salaries are paid by the national health system, an MSF nurse has trained laboratory technicians from the hospital on our approach and MSF plans to provide needed medicines until December 2004.

Providing primary health care to Romas In June 2003, MSF general practitioners started working in a primary health care center in Fakulteta, the biggest Roma community in Sofia. Today, six GPs cover a population of about 20,000 people. In May 2004, more than 7,000 patients (including 1,000 children under the age of 5) registered with these GPs.

In order to improve access to health services, MSF employs five community outreach workers. They promote the clinic, registration with GPs, and refer other social problems to the relevant institutions. The GPs have started a foundation under Bulgarian law in order to take over the project's activities in early 2005.

Last August, Bulgarian health authorities determined that only 40-60 percent of the children in Fakulteta had all of their required vaccinations. A "catch-up" campaign to vaccinate vulnerable children against DPT, polio and measles took place between March and June 2004 in collaboration with local authorities.