Good intentions and vague promises surrounded the long-awaited National Health Strategy 2008-2013, which was ratified by Cabinet on October 2.

Approval was postponed several times in the past because the Government claimed it had to review the contents of the strategy to ensure it was in line with the latest trends in health care. One such trend worldwide is the introduction of private health insurance funds in the sector of mandatory health contributions, giving people more choices as to how they fund their health care, unlike the present system in which Bulgaria has just one state body that handles health insurance contributions.

The subject of breaking the monopoly of the state-owned National Health Insurance Fund (NHIF) was briefly mentioned in the otherwise long and detailed document adopted by Cabinet. The relevant line says that the strategy would "introduce competition in health care financing, keep the mandatory health contribution care principle while at the same time include private health care funds in it".

The strategy said nothing about when competition would be introduced. But, judging by its timeframe, it could well happen by the end of 2013. The document also contains a line about private health funds being allowed to operate alongside mandatory contributions to the NHIF, creating doubts about how competitive the process will be. Furthermore the strategy said nothing about the idea of increasing mandatory contributions from six to eight per cent from next year. Nor did it state whether the two per cent increase would go to the NHIF or to the private health insurance funds, which was one of the ideas discussed by the three ruling parties.

Common idea
The plan to de-monopolise mandatory health care contributions has been agreed in principle by the tripartite ruling coalition. The problem remains as to how and when it will happen. At present all employees pay their contributions to the NHIF, which in turn covers anyone who needs medical treatment. No one seems happy with this, neither the contributors nor those whose treatment is covered by the NHIF. There are a number of reasons for this. One is the fact that pensioners outnumber people in employment, which means that a small group is paying for the health care of a large one.

The other issue is the way the NHIF manages the millions it collects every month, as it has constantly being accused of a lack of transparency, unreasonable spending and corruption. If these accusations had come from the opposition, things might have been different, and it has been the subject of heated debate within the ruling coalition.

In recent years, heading the criticism has been the National Movement for Stability and Progress (NMSP), which has long campaigned for private health funds to operate in Bulgaria's mandatory health care contribution sector from 2009 onwards.

The issue is sensitive because the Health Ministry that defines health care policy is under the control of the senior coalition partner, the Bulgarian Socialist Party (BSP). BSP had expressed doubts that the NHIF could survive the competition for private funds in a competitive market, which would affect people with low incomes. The third coalition partner, the Movement for Rights and Freedoms, hasnominally expressed their support for the NMSP's campaign but have done little to make it happen. Nothing has been done about the issue other than forming a working group of the three parties' MPs. The group provisionally agreed on the need to destroy the NHIF monopoly but from all that has been said so far it seems that the change will not happen next year, but in 2010.

Health policy
None of this would have made much difference if it were not for the fact that Bulgaria is to have its next regular general elections for Parliament in the spring or summer of 2009. That means that a new government, not the current one, would have to take care of reforming health care contributions.
Health Minister Evgenii Zhelev confirmed this in a statement to Bulgarian National Radio on October 5. He said that private healthcare funds could start signing up clients and patients from 2009, when funds will be licensed by the state to collect mandatory health care contributions. He went on to say, however, that the funding system could be reformed as early as 2010.

Meanwhile, the BSP-dominated Government has taken steps to ensure that, in light of the forthcoming elections, should the sector be de-monopolised earlier, the NHIF system should stay in place. This is how you could read the line saying, "the mandatory health care contribution principles will continue to exist". Unfortunately, another omission in the strategy was how the mandatory contribution system will co-exist with the voluntary contributions people might prefer, especially in the light of the 18 voluntary health care insurers that have been registered in the country so far, with more in line waiting to be licensed.