A public discussion was held in Parliament this month on the topic of "Strategic Directions in Health Care".

Those taking part included the Minister of Health, the chairperson and deputy chairperson of Parliament’s committee on health care, representatives of organisations of health care professionals, trade unions, and the National Health Insurance Fund governing body. What became apparent from the speeches given by the participants?

1) Privatisation of pre-hospital care is planned.
This should have happened a long time ago, and that is why it is necessary that it becomes a reality as soon as possible.

2) Hospitals concessions are planned.
This is also a good idea, but presented with the phrase “the effect will be negative...and it will lead to an increase in public expenditure”, it is a little confusing. In principle, concessions are a way of generating resources for those who provide a concession, meaning the Government, and concessions should lead to a decrease in expenditure. Of course, if the goal is to give concessions without the use of auctions or competitions, as was the case with Trakia Highway, the results would be lamentable – but let us hope that such an approach will not be used again.

3) There are no plans to break the monopoly of the state National Health Insurance Fund (NHIF).
Not one of those who spoke at the event, besides the author of this article, expressed support for setting up private insurance funds that would compete with the NHIF. This means that we will have to wait for a while before any competition appears, competition that would lead to an improvement in the quality of service and the availability of a choice for all citizens who pay their health insurance fees and for all those who rely on using the system. To illustrate this apparent absurdity, imagine that there is a single bank in the country and that the value of the savings deposited in this bank is less than the value of the loans that it granted – what interest rates would this bank offer, what kinds of products would it offer, and would it have any incentive to do anything at all in order to attract or retain customers? And if, at the same time, the people in power were claiming that a bank is a very important and complex “thing” and the private sector would not manage with such an activity, and the state must allocate more funds to cover the difference between the total value of the deposits and that of the loans?   

4) “The NHIF is not bankrupt”, but still “there is a need for more funds from the budget”.
To the claim that the National Health Insurance Fund has been on the verge of bankruptcy for years, the Minister of Health said that the NHIF was still working, which meant that it was certainly not bankrupt yet. The question, however, is how and from where it is getting its funds. In our opinion, if the revenues from health insurance payments are insufficient to cover the expenses of the NHIF, it is de facto bankrupt. The chronic deficit that has to be covered by the budget at the end of the year means that the system is ineffective.

5) There is an idea to unite the professional organisations of medical specialists and workers in a Bulgarian Medical Chamber.
This, of course, should have been expected, because only those in Bulgaria that still have not thought of creating a nationally representative professional organisation, have not done so yet. And if at the moment there is a Bulgarian Pharmaceutical Union, a Bulgarian Doctors’ Union, a Union of Bulgarian Dentists, a Bulgarian Association of Health Care Professionals, and each of these has come up with rules regulating their respective professions, that it is almost getting too difficult for non-member practitioners to breathe, then probably a common chamber will make medical professions the most regulated in Bulgaria. And the chance to reach agreement within such a chamber on any issue will be a major challenge.

6) The introduction of a system for cutting spending on health care is planned.
Unreservedly, this is perhaps one of the most sensible ideas about health care to have appeared recently in the public domain. But, like other systems such as the NHIF or the tax authorities, it probably will not be implemented in the next 10 years.

In summary, we should say that some of the participants clearly announced their opposition to most of the sensible reforms that were proposed, and requested more money. Others said that the reforms were to proceed, but more money will nonetheless be needed. But who is going to provide this money? And should we continue to pour water into a leakey bucket, before patching up the holes on its bottom?

Svetla Kostadinova, Executive Director, Institute for Market Economics