Another year in which health is assigned a lot less money than the sums which are expected to be consumed, and then the budget of the main payer – the Health Insurance Fund – has to be updated or payments have to be postponed is coming to an end. This is another year in which a third minister is being changed in the leading position of the sector only in a few months. The heritage from the time of Tanya Andreeva was the writing of such a bad draft bill for a full year that ultimately it was not voted and supported even by her own coalition. There was the strike in the Emergency sector, the many misplaced personnel reshuffles and attempted dismissals, the numerous public contracts which were subsequently cancelled, and an unresolved crisis for the reason of which there were no vaccines from the mandatory immunization calendar for a long time.

The set in the beginning of the year deficit of about 400 million BGN from the budget of the NHIF forced the MP-s to vote two consecutive updates of the resources of the National Health Insurance Fund. In its turn it presented a disturbing analyzes of the health sector and outlined the main problems in the system.

The new team of the Health Ministry is facing the challenge of making the emergency services work, of satisfying the huge public demand for modern treatment of high quality and of giving hope to the disappointed doctors and medical workers that their work will be evaluated and that leaving the country makes no sense.

A beginning or the end of the reform?

The frozen in 2001 health reform left the sector in a semi-market state, in which there was only one clear market price – that of  medicines. All other medical services were valued not on the basis of their treatment quality, real labor costs, staff qualifications, but based on the draft budget of the NHIF. This way all hospitals received the same amount regardless of the outcome of their activities. The Bulgarian health system does not link the financial input to the performance due to the distorted model of clinical pathways, which leads to increased and difficult to control costs in the sector, an increased number of hospitalizations despite the declining population, unchanged quality and inability to make a real assessment of the service.

In actual fact, Bulgaria is the European country with the lowest percentage of GDP devoted to health – 4%, and the highest surcharge – about 47.75% – of the household budget is spent on health services and medications. When it comes to healthcare, Bulgaria virtually is a country outside the EU – with the lowest percentage spent on healthcare, with the highest surcharge, with the largest number of years spent in illness – between 11 and 15 per person, and one of the lowest life expectancy – 74 years. For comparison – over 965 thousand Bulgarians are aged over 70 years, and the degree of care for the elderly is extremely neglected. The largest group of patients – those suffering from cardiovascular diseases, for example, receive 25% drug coverage from the Health Insurance Fund.  Violated is the main principle – that of solidarity.

There are two reasons – a huge number of people, between 1.3 million and 2 million people, do not pay for healthcare and rely only on Emergency services and, moreover, the state does not provide the full amount of funds for the people for which it pays itself.

The budget of the main payer – the Health Insurance Fund – virtually relies on contributions from approximately 1.7 million contributors, people from the private sector, whose contributions average 60 BGN insurance per month, or a total of 1.9 billion BGN per year. At the same time the state provides for 4.5 million people – pensioners, children, students, civil servants, the army, police and judiciary, an amount less than 20 BGN per month. Virtually, the state pays for all insured the same total amount of 941 million BGN, and in 2014 – 975 million, while the insurance sums do not match even the minimum payment.

In actual fact, the budget of NHIF was 2.8 billion BGN, and the total sum for healthcare in 2013 was 3.4 billion BGN. In 2013 the public expenditure on medicines was 927 million BGN, or approximately 33% of the expenditure of the NHIF and 27 % of the total public healthcare expenditure. The public expenditure on drugs in Eastern Europe varies around 25% of the public health expenditure. Bulgaria is part of this trend, but in order for this to be a fair comparison, it should be clear that a substantial part of the public expenditure on drugs, namely 154 million, is due to the charging of VAT on all payments for drugs coming from the NHIF and the medical institutions. In Eastern Europe there is no country which applies such a value added tax on medication. In this sense, the public expenditure on medicines in Bulgaria without VAT is 770 million BGN, or nearly 23% of the public expenditure.

The overall effect of talking about drugs by doctors went so far that during the first update of the NHIF budget in the summer it was completely forgotten about the missing 100 million BGN exactly for the medicines for home treatment – the only direct payment which patients receive personally from the Health Fund. In the same period another change took place – the list of drugs that the NHIF covered stopped being updated twice a year, and switched to being updated once a year with new therapies. In respect to oncologic drugs the decision was declared illegal by the Supreme Administrative Court.

Nevertheless the talk about drugs continued and before leaving her position, Tanya Andreeva approved another anti-market change in the regulation of prices on over the counter medicines – another temporary freeze on the prices of market impulse purchases, from which not a single penny is covered by the state. In the election programs of almost all political parties were included the optimization of the payments for medicines and stimulating the generic policy.

The expectations are mixed, but it is apparent that the system should be oriented to pay for the benefits of treatment, for being cured, for quality, and not to be unable to follow the development of almost any patient who moves between the general practitioner, specialists, the hospital and back.

How (not) to regulate?

The beginning of the autumn of 2014 will be remembered for one of the most visible personnel scandals in the health sector. From three consecutive audit reports it was found that the drug regulator – the BDA – has been appointing completely incompetent persons.

Principally in the sector it was quite clear that the last two directors were close to
the owner of one of the four national distributors and the largest pharmacy chain in Bulgaria – the Varna businessman Veselin Mareshki.

After a signal to the prosecution of the new Executive Director of the BDA – Assoc. Prof. Asena Stoimenova – it became clear that the several successive governments have left drug regulators as inspectors controlling the market the aunt of the businessman, his lawyer, the technician of the holding, a cashier in his pharmacies, and the like.

The incompetence and pressure, which people whispered about, virtually proved to have dimensions which endanger safe use and competition. A signal for this were the declarations of practically the whole sector, which with joint statements insisted for a strong, independent and professional regulator.

Who really works?

Some of the main indicators of what is happening in the health sector are still missing – these are the medical standards for quality work. There are no records of mortality, hospital-acquired infections, and consecutive admissions to hospital. The need for absolute clarity, which would allow full synchronization between the information systems of the Health Insurance Fund, the health institutions and the doctors, is increasingly apparent. It is one of the first election promises which the sector expects to be carried out quickly.

The other thing is the ability for de-monopolization of the Health Fund and the selection of a private Health Fund into which to transfer part of the insurance – a change that would motivate those who pay the most, but use the least because of the huge queues of other patients, to choose the best doctors through their fund.

There are so many hopes that even a small disappointment from changes that do not take place would demotivate more and more doctors and patients.