From February 1, the National Health Insurance Fund (NHIF) is cutting off cash for 21 municipal and private hospitals as part of the Health Ministry’s controversial and long-awaited hospital care reform plan.

The NHIF decision, announced on January 26, means that these hospitals will have to rely on other sources of money – but, more likely, that they will close.

The hospitals’ NHIF funding is being shut down because they failed to meet one of the fund’s main criteria, set by the Health Ministry, of having at least two specialists working full-time on what are known as "clinical paths".  The reform plan envisages that such specialists will provide a 24-hour service, which currently a number of hospitals do not do.

The strategy has led to allegations that the changes favour hospitals in major cities at the expense of smaller ones. Deputy Finance Minister Vladislav Goranov, who chairs the NHIF management board, responded:  "Making cuts is not the main goal of the reform, but rather selecting the hospitals that can provide proper treatment".

The "clinical path" is a system of requests and procedures for various medical specialties for the hospital treatment of patients with certain diseases covered by NHIF payments to hospitals. These payments are directly related to the quality of the medical assistance provided according to the clinical path.

In 2009, there were 371 state-owned, municipal, private and university hospitals getting money from the NHIF on the basis of the "clinical path" system. This system is mainly funded by the compulsory health contributions paid by employed Bulgarians.

Given that various statistics say that about a million Bulgarians fail to pay contributions – either because they do not believe that they get value for money or just do not want to pay their dues to the state – there is not enough money to maintain satisfactory standards at the 371 hospitals.

The Health Ministry said that this meant that many hospitals in remote areas, with predominantly elderly communities, were getting NHIF money even though they did not provide proper care.

The ministry said that this money could be better used where hospitals had the qualified staff and equipment to provide specialised and expensive treatment. In other words, the system of 371 hospitals (a legacy of the communist era when almost every town had its own hospital) had to be restructured, all in the name of people’s health. To do this, the ministry chose what opponents of the plan call an administrative and not a practical approach, which set criteria for hospital care.

This approach, according to medics who gathered in Sofia on January 22 to discuss the reform plan, would benefit the big regional hospitals which the ministry says would treat patients whose local hospitals had been closed.

The ministry’s opponents say that the plan will leave people in remote areas effectively without medical care because they would have to travel for up to an hour to the nearest major hospital that meets the NHIF’s criteria.

Health Minister Bozhidar Danev said that hospitals that had failed to meet these criteria could be transformed into emergency care centres, able to take patients to a bigger hospital, or to work as clinics. These clinics would offer services such as check-ups, but not hospital care, because there was no sense in spending on care that was not of the required quality.

Danev said that another option was for people’s general practitioners to take some of the load. Critics say that the criterion requiring two specialists could not be applied uniformly because in many cases, there were too few patients to provide enough work to two doctors sharing the same specialization.

This requirement also had not been included in the 2010 framework agreement between NHIF and the Bulgarian Medical Union, and so the requirement was unlawful, critics said.