Do you know how you keep healthy? When food and medical services are of the highest quality and the overall environment is clean. This, at least, is the new Government’s aspiration as part of its fiscal budget framework. It also has an additional goal – to peg health contributions at current levels during its term and ensure that people’s money goes where it is most needed and not to some faceless medical bureaucrat.

Significantly, the black hole into which more than one billion leva disappears every year is called – a hospital. This was revealed by a report of experts commissioned by a previous government and paid for by the World Bank. The Bank bankrolled the health reform that was halted in 2001 before the restructuring and subsequent privatisation of the hospitals that provide the most expensive health services in the country.  

The unpalatable truth is that the former government concealed the report - for which it had paid - before the July 5 elections this year. The reasons are apparent: it suggests drastic reforms whereby half the 285 hospitals providing active treatments (those performing complicated operations that admit patients in a serious condition) would be scrapped and the entire medical system restructured, including the opening of hospices and establishments for the long-term treatment of elderly people and the chronically infirm.

The team of Health Minister Bozhidar Nanev said that in forthcoming weeks it will hold a public discussion on the report with medics, hospitals’ management boards and owners as well as municipalities and patients’ organisations. The aim is for every region and municipality in Bulgaria to have an idea how the restructuring process will be undertaken and in what form current medical establishments will operate in the future.

Waste of resources
Every country should be aware of its citizens’ health needs, what medical establishments are necessary and what sort of services need improvement. In Bulgaria, however, this stage of development exists only on paper.

According to the World Bank report, Bulgarian hospitals, in order to retain financial backing from the state National Health Insurance Fund (NHIF), tend to keep all admissions and register them officially as patients. Instead, they should concentrate on those needing serious treatment and caring for them effectively. Less severe cases, meanwhile, should be dispatched to more appropriate institutions.

The report says that in Bulgaria it is difficult to pinpoint patients’ real ailments because, after admission, hospitals are obliged to treat them under one diagnosis. Then, if side effects or complications occur, patients are simply dispatched to another hospital for further treatment, or re-admitted to the same hospital and treated for something else entirely.

On paper, 1.6 million Bulgarians out of the country’s 7.7 million population are treated every year. State, municipal and private hospitals usually offer a different type of service. In Bulgaria’s case, however, most hospitals are registered as multi-profile hospitals for active treatment, and should be able to cope with the most serious cases, when in fact this is not the case.

Out of a total of 130 provincial hospitals, only nine qualify under international standards as modern multi-profile hospitals and have more than 2000 operations performed annually. The logical question is why is it necessary for a hospital to exist and absorb financial resources for active treatment when it actually only handles patients with chronic diseases, the poor and the elderly and, as such, only executes social services rather than active treatment.

No independent agency is currently entrusted with evaluating hospital services and quality in Bulgaria. Assessments and hospital accreditations are made by the Health Ministry.

According to the report, on paper at least, most Bulgarian clinics and hospitals are in excellent shape. However, in most of them there has been no substantial investment in training or equipment because the hospitals are in poor municipalities. Where the state did invest in certain equipment, it is in most instances a case of investing in ineffective branches.

Thus the problem with hospital management is immense. The largest establishments are state property; their board members are appointed by the Health Minister in accordance with political allegiance. Most hospital managers combine the governance of hospitals with their work as doctors.

The World Bank says that every Bulgarian municipality has between 33 and 59 multi-profile hospitals, but this has neither improved the quality nor the safety of patients, or the effectiveness of services, judging by European and world standards. It is precisely those clinics that urgently require restructuring and most need their services and standards improved and made effective.