EKIP– Expert Club for Economics and Politics A Different Opinion
IMPORTANT CLARIFICATION: The article was originally published on the website of the newspaper "SEGA". As a result of a DEliberate semantic editing, corrections were made to the text WITHOUT being coordinated with the author. Therefore, we are now publishing the original of the article. We believe that the editorial staff of the newspaper "SEGA" owes the necessary apology for the semantic changes that were made and for which the author was not notified in advance.
Every month we witness scandals and problems of various kinds in Bulgarian healthcare, which are mainly reflected in their political and rarely in their economic nature. Healthcare in Bulgaria is the sphere in which historical political-economic interests are intertwined, dating back to the years before the changes. Real policies are made by the middle administrative echelon, while the responsibility for the decisions taken is borne by the person appointed as minister. Bureaucratic violence (according to Berdyaev) reigns in the sphere and dictates the rules of stagnation. That is why since 1999, not a single more radical reform has been carried out that would lay the foundations for sustainable development in the sphere.
Regarding hospital care:
The total number of hospital care facilities in the country in 2020 is 360. Of these, state and municipal facilities are approximately 2/3, the remaining 1/3 are private. The publicly discussed problems with hospital care mainly concern the share of state and municipal companies, due to objective factors related to the quality of their management, their income from clinical pathways and the desire of patients to be treated there. At the beginning of 2019, as a result of a decrease in the value of one of the clinical pathways, the Association of Municipal Hospitals conducted an analysis and found that approximately 50% of their income depends on it, it is related to the treatment of neurological diseases of the spine. Each of the municipal hospitals is considered "multi-profile" on paper, but in reality half of their income comes from one profile. This also speaks to the quality of the services provided in the respective medical facility, as well as the medical standards that are observed.
There is an economic imbalance between public and private hospital companies. On the one hand, private hospitals can make a profit, which is not allowed for those in the public sector. On the other hand, for mismanagement and inefficient spending of funds, the responsibility in public hospitals is borne by taxpayers, while private hospitals themselves pay for their mistakes. Another part of the problem concerns the selection of patients, which is carried out by some hospitals in the private sector, which leave the more serious or urgent cases to the public ones and focus mainly on the planned admission of patients, which in turn leads to fewer losses for the respective institution and more for those who are obliged to accept it.
Part of the solutions to the large number of inefficient hospital companies, as well as those that do not meet medical standards, are rooted in the words consolidation, privatization or liquidation. The problem with the transition to such activities and in particular to privatization is the moratorium on hospital privatization imposed in 2001. Over the years, there have been sporadic attempts to lift it, which have been marred by populism and fear of the fall of the respective government from power. On the other hand, the reduction of private hospitals is rooted in whether, despite the failure to meet medical standards, they are allowed to conclude contracts with the NHIF for certain clinical pathways.
Regarding medications:
Medicines are the most regulated part of domestic healthcare. Their price is the lowest compared to other European Union member states, and yet the main perception of patients in Bulgaria is that they are expensive. The problem is not that the price is high, but that the highest co-payment is made for medicines compared to the average European values. The macro picture in the country shows that patients pay an average of about 65% for medicines, 20% for outpatient care and 15% for hospital care. The co-payment is most pronounced for medicines for cardiovascular diseases, where the NHIF reimburses about 25% of the cost, resulting in about 1.5 million patients paying 75% of the cost of their prescribed medicine. A significant part of the patients in this group are people of retirement age, and such a co-payment negatively affects their monthly budget, since they have to choose which of their basic needs to cover first. Looking from the angle of state policy and the recommendations of the European Commission that co-payments for medications are high, the Bulgarian state does nothing on the subject to inform patients about what medications they are prescribed, nor about the alternatives to their treatment. According to the Health Act, the doctor is obliged to provide this information to his patients. Due to the lack of an electronic prescription and verification by the patient - such information is missing in the system.
The problem with tenders in hospitals - abuses are observed both in state and municipal institutions and in private ones. In public companies, preferential treatment of original and biological medicines is observed at the expense of generic and biosimilar medicines, which have the same therapeutic effect, but at a much lower price. The problems with the purchase of medicines in private hospitals concern the mechanism by which the fund pays the final price of the purchased product and the fact that it cannot track whether the price has not been increased several times by the wholesaler who resells the medicine to the hospital with which it is indirectly linked. Since private hospitals are not obliged to hold tenders compared to public ones - they can demand reimbursement of the price of a given product at its reimbursement value, according to the Positive Medicine List. While public companies have purchased it at a several times lower price.
The reform in the pharmaceutical sector should be in several parts - informing patients about the alternatives to their treatment, in order to avoid the speculation that if a drug is cheaper, it is therefore less effective. The second step would be incentives for doctors who save money for patients and the National Health Insurance Fund, as a result of prescribing cost-effective therapies. Last but not least - reducing overregulation in the sector, leading to basic and well-established therapies, as well as innovative ones, leaving the market because their price is driven below cost.
We can talk about the state of the system through a Russian proverb “We wanted better, but it turned out as always” or, in Bulgarian, we wanted it to be better, but it turned out as always. In order to break the stagnation, a change of generations is needed. The April generation is heading towards its natural replacement by the coming ones, who, although educated and trained by it, are one step closer to the future than their teachers.
