Average number of new cases per year in Bulgaria: 110 cases with clefts of the lip and/or palate, 40 with other facial anomalies for a population of 8 million people. About 30% of the children with cleft lip and\or palate are left in orphanages because of lack of information to the parents and negative social perception. In the last years several poor families believe that the treatment of heir child will cost too much and left the child in an orphanage until the lip is operated.

• Since 1989 the Social Security System is still not very functional and well established. During last 10 years the health care is in permanent shortage of funds and the finances given from the state are never enough. For some periods the non life-saving surgical operations including cleft lip and palate surgery were forbidden by the hospital authorities, for the reason of lack of funds. In Bulgaria The National Health Insurance Company started functioning in 2001 but the treatment of the patients with clefts lip and palate is not included in the list of reimbursed treatments until April 2003. Since then for every lip and/or palate cleft operation 250 Euros are paid to the hospital. Part of this amount - 45 Euros is transferred to the surgical service where the operation was done. In the system of health care is applied the regional principle and not the principle of the specialized centre. The result is that every department of plastic or maxillofacial surgery without any experience in this pathology, having 5-6 cases per year will be paid without providing a multidisciplinary care. Another problem is that most of the materials and products necessary for an intervention are not delivered to the right surgical service. There are no payments foreseeing for orthodontic care, speech therapy and ENT treatments. There is no legislation considering problems related to this kind of malformations. We have sent a lot of letters to the Ministry of Health and to The National Health Insurance Company without succeeding to influence the absence of interest. In 2003 one of our interventions via Eurocleft provoked some echos, but unfortunately without reaching any changes in the situation.
• At the moment the donations in Bulgaria do not reduce the sponsors' taxes. Before the creation of ALA there were no guaranties for the appropriated use of the donations and for the respect of the sponsors' wishes.
• "The condition is not treated as a priority by the health authorities" abstract from the report of Eurocleft Standards of Care for Cleft Lip and Palate in Europe.

   The Unit of Plastic and Craniofacial surgery in Plovdiv is the sole centre recognized by EUROCLEFT-EUROCRAN to be a Specialized Centre in the care of clefts lip and palate in Bulgaria.
   In 2003 a contract was signed between the University hospital and Ward in Plovdiv and Eurocran - for Workpackage 2 (which is a research program for the genetic causes and environmental factors for cleft lip and cleft palate). In September 2003 the Ward in Plovdiv together with teams in Hungary, Slovenia, Slovakia and Estonia start working on a multicentric project of Workpackage 1 of EUROCRAN (a clinical comparative study on 6-8 years old patients with total unilateral cleft).
   In November 2003 the specialists from the Plastic and Cranio-facial Ward of Plovdiv initiated THE FIRST NATIONAL MEETING of the specialists working in field of clef lip and palate. The meeting coincided with the national conference of the speech therapists in Bulgaria.

At the meeting took part - Dr. Simeon Daraktchiev from the Health Ministry (at right on the right picture) and Associate prof. Dimitar Evstatiev - Head of the Plastic Surgery Department in Sofia (at left on the right picture) and Prof. Moutafchiev - Head of the Chair of Othodontics in Sofia. At the meeting were present almost all the specialists from the Orthodontic Department from Sofia as a lot of speech therapists from all over the country (on the left picture-Ass. prof. Evstatiev -surgeon, Ass. prof. Emil Gueorguiev- surgeon, Dr. Laura Andreeva - orthodontist, Dr. Jelev - surgeon from Varna).

   In the past the treatment of clefts lip and palate consisted mainly in a surgical intervention. By priority it used to be done in Sofia, Plovdiv and Varna. In the last 3 years the situation is not changed and the cases are treated in those three cities. The orthodontic treatment and the speech therapy were not in relation with the surgical treatment. Toward 1980 a multidisciplinary team was formed in Sofia where the main part of the cases was treated. In 1996 a new Unit of Plastic and Cranio-facial Surgery with 10 hospitals' beds was opened at the University Hospital in Plovdiv. The person in charge of this Unit became Dr. Anastassov one of the students of Prof. Philippe Pellerin from Lille, France. Since 1996 the protocol and the philosophy of the French cleft care are applied in the Unit in Plovdiv where are concentrated 70 % of the cases in Bulgaria. In 2001 between the University Hospital Plovdiv and the Surgical Hospital in Lille was singed a contract for cooperation and fellowship.

   The French help in the care of cleft lip and palate is considerable being as well intellectual as material. Several times instruments and consumables are transferred from the Lille Hospital to the Ward in Plovdiv. In November 2003, the KIWANIS from Seclin, France donated to ALA a microbus together with the Hospital of Lille, considerable medical equipment such as surgical table, machine for anesthesia, instruments, medicines and computers.

   At the Ward work three surgeons, one maxillofacial specialist and two plastic surgeons, 6 nurses and 3 hospital attendants. A speech therapist - Ludmila Epitropova, an ENT doctor - Dr. Djambazov, an orthodontist - Dr. Simova and a dentist - Dr. Nikolova participate at the week consultations of the patients with cleft. Since 2002 another speech therapist - Teodora Spassova is part time employed for the Department of Neurology. As her own interests are related to the speech problems of the patients with cleft lip and/or palate she is actually working diagnosis and therapy for full time at the Plastic unit in Plovdiv.

   Since the year 2000 we have full and precise documentation for every one of the patients. All the data is kept in personal folder including photos, we make plaster molds of initial status which give the possibility to evaluate the results. The ENT examinations are becoming routine as well as the set up of transtympanic drains. The speech examination is competed by the means of an aerophonoscope of Delaire. In the field of the orthodontic care we are developing the use of nickel - titane arcs with memory and the quod helix system with some modifications in the time of the alveoloplasty.