One of the busiest crossroads in Sofia was closed between 8.30am and 9am every day between June 12 and June 15 with only trams allowed to cross. The reason was not repair work.

Every morning the intersection of Tsar Boris III and Pencho Slaveikov boulevards was crowded with people dressed in white. More than 250 Pirogov National Emergency Centre staff protested to demand increased salaries and better working conditions.

The first such protest, on May 18, was spontaneous. This time round, it was co-ordinated with Sofia Municipality, as the law requires, and the municipality changed the routes of two bus lines to avoid massive traffic jams. People were advised to avoid the intersection in the morning. Police were sent to guard the protesting medical staff.

A change in the way salaries are paid by the state is the first demand raised by the doctors and the other medical staff. Pirogov doctors currently get between 500 and 560 leva a month. Nurses’ salaries vary between 250 leva and 300 leva. The protesters requested from the Government and Health Minister Radoslav Gaidarski that the state allocate additional funds to emergency medical centres such as Pirogov because they had needs and expenses different to those of other hospitals in Bulgaria. The demands were addressed directly to Prime Minister Sergei Stanishev, Gaidarski and Parliament’s committee on health care.

Protesters outside Pirogov said that the worst problems at the hospital were not only the low salaries but also the old-fashioned and out-of-date medical equipment and the status that Pirogov had as a hospital.

They demanded that Pirogov be included on the list of hospitals that have the status of national hospitals. They hold that this will enable Pirogov to get more money from the state. They said that Pirogov had nothing in common with an ordinary hospital centre, because it takes care of all risk emergency cases, that are transferred from all over the country to Pirogov. Such treatment usually is very expensive and the money allocated to the hospital is simply not enough, medics said.

To better understand the medics’ demands, a short overview is needed of how Bulgaria’s health care system is organised.

The Health Insurance Law adopted by Parliament in 1998 introduced a Bismarckian type of health insurance system, with only one health insurance agency and mandatory health insurance payments deducted from personal income. Parliament decides the size of health insurance payments and each year determines the budget of the National Health Insurance Fund. Hospitals have individual contracts with the NHIF and become the providers of medical care in the system of the compulsory medical insurance. The hospital care on the basis of compulsory insurance is done in the form of agreement “packages” or “clinical paths” paid by the national fund without any payment by the insured individual. The “clinical path” is a system of requests and procedures for the different medical specialties for the hospital treatment of patients with certain diseases included in the legal framework, which are paid by the National Fund. The “clinical path”, in its own way, acts as a tool to ensure the quality of medical treatment, because payment in hospitals is directly related to the quality of the medical assistance provided according to the relevant clinical path.

When a patient is admitted in Pirogov, the medics evaluate the patient’s condition and decide which “clinical path” covers the expenses of the treatment. After the patient is treated, the medics send reports to the NHIF and NHIF covers the costs of the treatment. If, however, a patient has been treated in a way not covered by any of the “clinical paths” or simply the money spent by the hospital exceeds the money provided in the “clinical path”, then the hospital must cover the difference out of its own budget. This means lower salaries and lack of any funds for new equipment, Pirogov’s medics claim. However, Pirogov is a national emergency centre that treats the worst cases: cases on which other hospitals had refused to work because of the system outlined above.

Pirogov acts as the last stop for such patients. In a way, Pirogov medical staff has to choose between treating a patient and spending money from their own budget that will not be covered by the state, and not treating the patient at all.

This was why Pirogov medical staff had pink ribbons on their lapels reading “I treat my patients out of my salary”.

“This means that the more we work, the less money we get paid,” Krastyu Penchev of the strike committee told journalists.

“We don’t want to go ahead with a strike but our hospital is dying and we have no other choice,” Penchev said.

By June 13, Prime Minister Sergei Stanishev had not responded to the letter sent to him by staff about their pressing problems.

However, medics from other hospitals in Sofia and elsewhere in the country expressed solidarity with the medics.

Members of the public described Pirogov’s protests as being reasonable and even the massive traffic jams created because of the protests did not turn people against them. The Pirogov protests were supported by the Bulgarian Medical Association.

Medics from emergency centres in Veliko Turnovo and Gorna Oryahovitsa announced their support for Pirogov. Medical staff at the emergency centres in the Black Sea cities of Varna and Bourgas adopted declarations endorsing the demands of the Pirogov staff.

The medics’ protest was attended by the chairperson of the Bulgarian Association of Taxi Driver Trade Unions, Stefan Bosnov, who said that the association supported all people protesting against low wages in Bulgaria, including health care workers.

Although Stanishev had not yet replied to the medics’ letter, they appeared to have some reason to hope that their protests might lead to a change. This hope emerges from what happened on May 14, a week before Bulgaria’s May 20 elections of members of the European Parliament. Facing a strike by Sofia City Transport company drivers, the municipality raised their salaries to up to 800 leva a month. What the medics might have got wrong is their timing. The next elections in Bulgaria are the municipal elections in the autumn.