EKIP– Expert Club for Economics and Politics A Different Opinion
The principle of "no dissatisfied" is particularly strongly respected in the pre-election situation in Bulgaria. This year, the elections are double, and the expectations are the same. The promise of the ruling party that no hospitals will be closed during their term speaks well enough about the attitude they have towards reforms in the healthcare system. In order for the political path to be strewn only with laurel wreaths, and not with thorns, we have reached a situation in which, in less than 4 months from the beginning of the year, an additional 90 million leva has been distributed from the central budget - 10 million for psychiatric hospitals, 30 million for municipal hospitals, and last week - 50 million for raising the salaries of nurses and healthcare professionals.
The average ratio of nurses to doctors in the European Union is 2 to 1, i.e. in order to perform their duties according to standard, each doctor's team must have 2 nurses to support their work. In Bulgaria, this ratio in 2018 was 0.9 to 1, a signal of a chronic shortage of nurses and healthcare professionals in the system.
Part of the problems come from the low salaries of nurses, but it is important to emphasize that this applies mainly to staff who work outside large settlements. The other problem that is brewing is the production of staff - in 1999 the number of nursing graduates was 1600, and currently it has dropped to an average of 300 per year. On the one hand, this is a result of the state policy for the production of staff, but on the other, there is an interest from representatives of the professional organizations of nurses and healthcare professionals to keep the number of young specialists graduating relatively low in order to have higher salaries for the others who are already in the system. Or in short, protectionism.
There are 65 state hospitals in Bulgaria, and 130 municipal ones. Due to the lack of reforms in the sector - starting with the revaluation of clinical pathways, passing through the lack of a national health information system and ending with the poor management of state and municipal hospitals - we have reached a stalemate in which companies that went bankrupt years ago are only now falling into practical bankruptcy, thus creating the prerequisites for a lack of timely medical care for patients in small settlements.
A few months ago, the Supervisory Board of the National Health Insurance Fund (NHIF) decided to reduce the money for clinical pathway No. 56, which includes the treatment of nervous diseases, including disc herniations, polyneuropathies, etc. After this decision, the Association of Municipal Hospitals conducted its own analysis, in which it turned out that 50% of their income comes from this clinical pathway. Here it is worth recalling that these hospitals are multi-profile, and half of their income comes from one profile. And at the same time, they have contracts for many more clinical pathways than they perform. Here it is also worth recalling that despite the desire of the Ministry of Health to implement financial control and initiate reform, it is automatically accused by the Council of Ministers of a populist policy - not to close or privatize hospitals that have been proven to be ineffective for the health system, and more importantly - for patients.
The main income of the hospitals comes from the health fund, and the subsidy for the increase in salaries that the Ministry of Finance allocated was in relation to the budget of the Ministry of Health. It is not clear how this money will be allocated specifically to medical specialists in order to increase their salaries, as the main unit through which this can be done is the budget of each hospital, formed by the implementation of contracts with the health fund. Another serious problem is that there will be no equal treatment of some hospitals compared to others. Or, to be more precise, instead of encouraging successful hospitals, inefficient, unsuccessful and bankrupt companies will be encouraged. This accordingly removes any incentive for the remaining public hospitals to make efforts for good fiscal discipline, since money will always be allocated anyway, regardless of their economic behavior.
Everything listed so far fits into the definition of state aid – market distortion, use of public resources, creation of a selective advantage over certain market entities. According to the Treaty establishing the European Community, state aid is a prohibited fiscal instrument. And this is “any aid granted by the state or a municipality through state or municipal resources, directly or through other persons, in any form whatsoever, which distorts or threatens free competition by placing certain undertakings, the production or trade of certain goods, or the provision of certain services in a more favorable position”. Thus, it may turn out that as a result of these actions by the government, Bulgaria may be sued and have to pay much more than the 90 million leva allocated so far.
Original publication: The Economist magazine
Image source: BGNES
