DOES THE TEMP-DECISION CONTRIBUTE TO THE RESTORATION OF THE EMPLOYABILITY?

Introduction: A hot topic of the discussions about the reforming of the Territory Expert Medical Commission system (TEMC) is the restoration process of peoples’ health and ability to work. The expert decision, given by TEMC offers an opportunity for social adaptation for disabled people, whilst restoring their ability to work, all by using the methods and resources of rehabilitation. The aim of the article is to study and analyze the opinion of disabled people on the role of the expert’s decision by TEMC to restore employability. Material and Methods: The study’s sample was prepared on the basis of the register of General Territory Expert Medical Commission in the Hospital “St. Marina” Varna. The determination of the population includes preinspection of the register of General TEMC at University Hospital “St. Marina” Varna and the Regional Cardindex of Medical Expertise (RCME), Varna and covers 6000 patients with disability. A representative sample was formed on the basis of selection criteria and included 612 PD subject to certification and recertification of General Territory Expert Medical Commission at University Hospital “St. Marina” Varna for the period March-April 2018, which represents 10.25% of the population. Amongst the methods of the survey is a questionnaire, consisting of 15 questions in total (13 multiple-choice questions and 2 free-answer questions. The questions are organized in five domains: “organizational-methodical” (questions 2,6 and 7), “social” (questions 3, 5, 8, 9 and 11), “medical” (questions 1 and 4), “juridical” (questions 10, 12 and 13) and “opportunities for change” (questions 14 and 15). Standardized á-Crownbach 0.65. Results: Only 4.4% (n=612) of the people with disability, determined by TEMC-decision, think that rehabilitation that aims to restore their ability to work is enough. Those of them (81.9% (n=209)) who’ve been deprived of their percent for Permanently Diminished Working Capacity, report that they are not following the route of rehabilitation. The patients give different offers: a work recommendation must be included in the TEMC-decision (the type of labour must be synchronized with the given disability); the committee must influence the clinical and social rehabilitation that aims the restoration of temporary or permanent disability. Conclusions: The TEMC-decision does not help with the achievement of a prophylactic and rehabilitation function of the TEMC nor the restoration of the ability to work. There must be put an emphasis on a few subjects during the reforming process of the TEMCsystem, such as the activities regarding the restoration of work capacity, a prequalification according to the disability and a work recommendation.


INTRODUCTION
Solving of the problems of persons with disability is one of the most important priorities in the social policies of European Union member states. The relevance of the problem in Bulgaria is defined by the increase of disability cases under the circumstances of a rapidly ageing population in Bulgaria and the challenges faced by the system of disability medical assessment, the social services and the National Insurance Institute [1].
Socio-economic and political changes after November 1989 changed the way the system of disability medical assessment (DMA) functions. The legislative prerequisites for social rights occur after an expert decision issued by the regional disability medical assessment commissions (DMAC). It is a long and rough way to the acquisition of DMA and works as a barrier to the rights and social integration of persons with disabilities. The complicated situation requires measures for improvement of social and health policies not only on behalf of the governmental but regional level as well. This requires the adoption of a disability strategy which aims complex biological, psychological and social evaluation and rehabilitation for individuals with disabilities, their social inclusion and return to the labour market [2,3].
The reinforcement of the ability to work with a fixed period of rehabilitation as defined by the WHO Rehabilitation Committee (1958) aims at "preventing prolonged disability during the treatment of the disorder and helping disabled people to maximize their physical, mental, professional and socio-economic fullness within the framework of the existing disease or disability". The necessary actions of social policy in this direction can be reduced in general to two fields of action: actions that are directed directly to the person with a disability and closest social environment and actions forming the physical and social sphere [4,5,6].
The Bulgarian legislation defines the system of TEMC as an integral part of the diagnostic, medical and prophylactic activities of the medical institutions. TEMC assesses the rate of Permanently Diminished Working Capacity (PDWC), in percent of the healthy person. The expert decision determines the contraindicated working conditions and the persons are recruited at the discretion of the Commission. Properly dosed and well-chosen work is a healingprophylactic factor, but in the TEMC-decision does not determine its parameters, as well as a labour recommendation for a specific type of labour. According to the TEMC-deci-https://doi.org/10.5272/jimab.2020261.2921 sion, the person with inviolability seeks to realize the rights of many institutions, which are related to the rehabilitation process, and occupational rehabilitation [7,8].
The latter can happen in several ways: -Adaptation of places of work to the individual characteristics of workers with abilities; -The realization of projects related to the opening of new jobs for people with injuries; -Legal protection and labor-related consultations on labor, labor relations and rehabilitation of persons with disabilities; -Assessment of the occupational, managerial and working capacity of the injured person; -Development and improvement of the existing legal framework related to the labor rehabilitation of invalides; -Professional qualification and re-qualification of the disabled.
The aim of the article is to study and analyze the opinion of disabled people on the role of the expert's decision by TEMC to restore employability.

MATERIAL AND METHODS
The presented study is part of a DSc -research project on "Medico-social problems of handicap in the Medical Expertise System" (main investigator: P. Mancheva MD, PhD, DSc; Protocol/permission from 01. 03. 2018 by Ethical Commission Medical University-Varna) [9]. The empirical study is based on a survey of the opinion of 612 persons with a disability, who were recertified by TEMP by 2017, live in Varna District and appear in the Register of General TEMC at the University Hospital "St. Marina"-Varna and Regional Card-index of Medical Expertise (RCME). The sample represents 10.2% of those passed through the Commission for 2017 and is formed according to the inclusion and exclusion criteria.
The study's sample was prepared on the basis of the register of General TEMC in the Hospital "St. Marina" -Varna. The determination of the population includes preinspection of the register of General TEMC at University Hospital "St. Marina" -Varna and RCME-Varna and covers 6000 patients with disability (PD). A representative sample was formed on the basis of selection criteria and included612 PD subject to certification and re-certification of General TEMC at University Hospital "St. Marina" -Varna for the period Mart-April 2018, which represents 10.25% of the population.
The study's inclusion criteria: a certain degree of disability; living in Varna region; appearing in the register of General TEMC at University Hospital "St. Marina" -Varna and RCME-Varna.
The study's exclusion criteria: patients who first appear to TEMC; children.
Instruments -a questionnaire with 15 questions, out of which 13 closed and 2 open (app. 3), was developed by us, especially for this purpose. Questions are organized in the following domains: "organizational-methodical" (questions 2, 6 and 7), "social" (questions 3, 5, 8, 9 and 11), "medical" (questions 1 and 4), "juridical" (questions 10, 12 and 13) and "opportunities for change" (questions 14 and 15) and is of good reliability. The standardized á-Crown back is 0.65. Statistical processing of the results: The research was developed using the software products MS Excel 2010 and SPSS Version 24.0. Statistical methods used in the processing of the survey data are: statistical grouping of the data; descriptive (descriptive) methods; correlation analysis; nonparametric correlation coefficient of contingency.

RESULTS AND DISCUSSION
The study included 612 PD people represented by different age groups, gender, degree of disability, education, employment, family status, domicile. The socio-demographic characteristics of the respondents are shown in Table 1: Those who were discontinued at the PDWC rate at the last re-enhancement in 81.9% said they were not rehabilitating. The review of European experience in this direction reveals opportunities for these patients, but in Bulgarian terms, the law does not provide access to invalidity pension, tax relief, social privileges, incl. medical and social rehabilitation. Perhaps it is necessary to provide for a less restrictive regime for social adaptation for persons below 50% PDWC. Of the 144 persons retired in retirement age and 59 per cent state that they are not rehabilitated as a result of the TEMC decision, they have The distribution of respondents by gender is almost equal -51.6% men and 48.4% women. People predominant in the age range of 16-65 years are 85.9%, and only 14.1% are over 65 years old. More than half of the respondents (57.5%) have a fixed PDWC rate of 50 to 70%, 24.2% are 71 to 90%, and only 6.5% are over 9% -1.3% with foreign help and 5, 2% without help. At 11.8%, the PDWC rate was cancelled at the last re-certification. Without employment, they are 40.5%, working 35.9% and 23.5% -retirees on retirement age and age. The respondents in 64.1% are family members, and 59.6% live in a district town. The analysis of the demographic indicators of the persons included in the representative sample al-lows getting an idea of the characteristics of this vulnerable group from the community in the Varna region. In 85.9%, these are persons of working age (16 to 65 years old), who are 64.1%, living in a regional town at 59.6% and without hard work at 40.5%.
TEMC's in their decisions set out recommendations for further monitoring and rehabilitation of patients in compliance with Article 61 (2) (5) of the Ordinance on medical expertise, which provoked us to investigate the opinion of those concerned about the application of this legal option [10,11]. Persons with PDWC only in 5.0% of all respondents and 4.4% of all respondents in the study consider that rehabilitation is sufficient ( Table 2): ) in order to achieve the general goal -not only to enable people with disabilities to be socially involved but also to involve and adapt society and to accept disability as an inevitable but not insurmountable phenomenon.
Asked, "What do you want to change in legislation to improve physical recovery?" 41.4% of disabled employees respond that "rehabilitation should be in accordance with the condition of the sick person" -more often and as much as necessary Table 3): Pensioners maintain the same opinion in this respect in 45.1%, as well as 37.5% of people without employment. Only 9.5% of surveyed workers consider that rehabilitation should be a clause for receiving a disability pension. Therefore, after receiving the medical checkbook for their health status from the TEMC system, the respondents do not seek to restore their working capacity and return to the labor market, but they have to face the social benefits of the TEMC expert's decision.
It is assumed that the medical and social assessment contributes to positive changes in the situation of persons with disability, but when monitoring the respondents' answers to this question, we find that 253 persons with a certain degree of disability (46.9% of all 540 persons with PDWC in the study) report a lack of change, 28.15% "has improved" and only 5.93% -"has deteriorated". The remaining 72 respondents have no fixed percentage of PDWC, so they have not received a social assessment and have not realized rights. Their self-esteem is that in 44.44% their situation is the same, and even in 40.28% has worsened (Table 4):