The Bulgarian health care sector has urgently needed reform since the fall of Communism in 1989. All statistics make for grim reading. Life expectancy at birth is one of the lowest in the EU. Public health expenditure is insufficient, whereas out-of-pocket spending is the highest in Europe. The core of the system - the National Health Insurance Fund (NHIF), is chronically underfinanced, while the fund's foreign debts ballooned to over 270 million levs at the beginning of 2018.
For a country with an ageing population like Bulgaria, with a high rate of preventable mortality, low birth rate and labor shortages, change will be crucial in the coming years. Minister of Health Kiril Ananiev, a former Ministry of Finance official, vowed to take up the cudgels when he took office in November 2017.
Everything seemed hunky-dory for some time - doctors, experts, business representatives, trade unions and public sector employees were meeting daily at the ministry to discuss potential improvements to health care legislation. The surprise came in October in the form of a package of reform proposals included in the transitional and final provisions accompanying the 2019 draft budget bill of state-run NHIF without prior debate or public discussion. In other words, the proposals were sneaked through the back door, not as draft amendments to the relevant health laws.
Most of the proposals introduce increased government intervention in the sector. Experts assessed some of them as egregious and aggressive, making the ministry remove them before going public with the NHIF budget draft. Government officials said that the package would undergo significant revisions before a vote in parliament. However, with public attitudes turning more negative by the day, and with local elections in Bulgaria looming next year, it is doubtful that the health ministry would take risks with big reform efforts.
The proposals
The health ministry proposed to establish a Medical Supervision Agency - a new mega-structure under government control tasked with licensing and overseeing doctors and hospitals. The new institution would bring together the existing agency for medical audit and the agency for transplantations. It would grant work permits to doctors, medical centers and hospitals, write medical practice rules, verify compliance with financing and medical treatment regulations and penalize or close down medical institutions, if necessary. The proposal suggests that doctors would be under the direct control of the government and in danger of political interference. The new agency would also be in charge of another proposed initiative - a nationwide re-licensing of hospitals.
Another proposed change would empower the National Council on Prices and Reimbursement of Medicines, the state-run body determining which medicines and at what prices are paid for by NHIF, to draft therapy manuals themselves without relying on the assistance of consultants and experts. In so doing, the government is taking responsibility for the treatment of any disease, experts say.
Yet another proposal envisages that doctors would be required to prescribe only the most cost-effective therapy. Critics claim that this requirement would imply choosing the cheapest medicine irrespective of the individual needs of every patient - something that the health ministry and NHIF have denied. Moreover, if doctors prescribe equivalent but more expensive medicines they would be fined, according to the draft.
The reactions
The draft budget of NHIF, which the parliament approved on first reading in early November, drew censure from doctors, health care professionals and patients alike. The chairman of the Bulgarian Medical Association Ivan Madjarov said that inadequate time had been allocated to discussions and analysis of the proposals. Moreover, doctors were eliminated from the decision-making process as a whole. Madjarov, however, believes that cost-effectiveness in treatment methods is a positive step forward but opposes the fining of doctors if they prescribe more expensive medicines.
The National Patients' Organization in Bulgaria voiced concerns about the introduction of near-universal changes without prior public discussion. "We do not believe that there will be a debate or reforms," said Stanimir Hasardzhiev, chairman of the umbrella organization.
"It looks like the Ministry of Health is trying to write new medical textbooks," commented the chairman of the National Association of General Practitioners Prof. Lyubomir Kirov with regard to the transitional and final provisions of the draft.
Facing opposition from both doctors and patients, the Ministry of Health and NHIF have already said that the most controversial proposals would be revised.
Upcoming revisions
In Bulgaria, a draft bill has to be adopted on first and second reading by parliament to become law. While the first reading is a look at the draft as a whole, the second one looks at it article by article. A draft can undergo significant revisions between the two readings. So far, it seems that the government will use this period to make significant changes to the draft budget bill of NHIF before the second reading.
One of those will undoubtedly concern the obligation for doctors to prescribe the most cost-effective (or cheapest) medicine available. The likely revisions will significantly limit the scope of the proposed article.
The director of NHIF, Decho Dechev, said that the cost-effectiveness requirement will not apply to all 1300 medicines paid for by the fund but only to those whose cost is 100% covered by NHIF such as insulin, psychiatric drugs and other expensive medicines. Drugs for cancer treatment, however, do not fall into this category. Current patients will continue with their prescribed treatment, but the new ones will be affected by the new cost-effectiveness requirement.
Some proposals may be toned down, but they will definitely stay in the bill in one form or another, for example, the establishment of a Medical Supervision Agency. Government officials have said the proposal for its establishment will not be withdrawn from the draft bill.
At this point, it is still uncertain which suggestions will finally make it through parliament and in what form. Currently, it looks like the government is attempting a quick reform without weighing up all its implied shortcomings. Criticism continues to mount and considering upcoming elections and public resentment toward the government, the health ministry is not in a position to take risks and will likely play it safe, scaling back its reform effort as a whole.
The Bulgarian health care sector has urgently needed reform since the fall of Communism in 1989. All statistics make for grim reading. Life expectancy at birth is one of the lowest in the EU. Public health expenditure is insufficient, whereas out-of-pocket spending is the highest in Europe. The core of the system - the National Health Insurance Fund (NHIF), is chronically underfinanced, while the fund's foreign debts ballooned to over 270 million levs at the beginning of 2018.
For a country with an ageing population like Bulgaria, with a high rate of preventable mortality, low birth rate and labor shortages, change will be crucial in the coming years. Minister of Health Kiril Ananiev, a former Ministry of Finance official, vowed to take up the cudgels when he took office in November 2017.
