Beyond any doubt, Bulgaria’s health care sector is in dire need of reform. But while the need for overhauling the system is not up for debate, there is little agreement on how it should be done.

As expected, the biggest question is how big a role the state should play. The two proposals now on the table would open the way for private health insurance providers on the market, but the Government, through the National Health Insurance Fund (NHIF), would remain the biggest player by far.

There are key differences between the plan drafted by the health and finance ministries and the one put forth by Luchezar Ivanov, the head of Parliament’s health care committee.

The Cabinet’s proposal would have NHIF provide a basic package of health care services and cover the treatment of a number of "socially important" illnesses. Additional expenses would be covered by private insurers.

Private funds would be allowed to compete against NHIF for the first time in 2011, but would face tough restrictions – they would not be allowed to deny service based on age or medical history and, in the first years of operation, would not be allowed to post a profit, according to the proposal by Health Minister Bozhidar Nanev.

Nanev’s plan envisions increasing mandatory health care contributions to 10 per cent, from a current eight per cent of income, with the increase going to a private insurance fund chosen by each taxpayer.

The Finance Ministry, however, was less keen on the figure and preferred to decide on the increase after it had carried out an analysis of how much medical services actually cost, Kapital weekly reported, quoting sources in the ministry. Once the figures were available, a more gradual increase in the mandatory contributions could be implemented.

Ivanov’s plan, while allowing private health insurers, would require NHIF to provide full coverage for state administration employees, pensioners, children and the poor. Overall, that would mean that NHIF would have to offer full coverage for about 4.5 million people.

"This way, we answer the question whether it is proper to give taxpayer money to private insurers. No public funds would be transferred to private companies, which would receive only voluntary contributions," Ivanov said when presenting his plan in Parliament.

Predictably, his proposal is opposed by the private insurers, who said that it would offer NHIF little incentive to improve the way it manages its funds, while forcing private insurers to build a competitive framework with a fraction of NHIF’s financial clout. According to Mimi Vitkova, chairperson of the association of private health insurers, Ivanov’s plan would mean that private insurers got about 200 million leva out of the 2.5 billion leva now being spent on health care.

Quality control
An integral part of the reform would be shutting down state-run hospitals to cut costs and make spending more efficient. Private insurers will, like NHIF, choose with which hospitals to have a contract.

The issue of health care services quality control, however, has been overshadowed thus far by the discussions on the financial aspects of reform.
The current proposals envision the hospital accreditation process to become optional, though only accredited hospitals would receive NHIF funding. The accreditation would be carried out by ministry’s new medical inspectorate and would be based on the equipment that hospitals owned. As the ministry operates the overwhelming majority of big hospitals in the country, this framework would not eliminate the prospect of conflicts of interest in the evaluation process.

Furthermore, the ministry inspectorate would have a total of 50 staff, which, critics said, would not be enough to fulfill its declared function of quality control of all health care services offered in the country.