The Health Reform Starts with Scandals

Service Funds Used on Repair Costs

AIM Sofia, July 3, 2000

For second consecutive year early June is a key period in the history of Bulgaria. After the denomination of the national currency, July 1, 2000 marked the beginning of the health reform. Although the denomination was successfully carried out, the beginning of the long-expected reform of the health sector was accompanied with good intentions, fears of failure and too many financial scandals.

Good Intentions

The health reform is aimed at halting the long-standing system of medical care which was paid for by the state, under which patients received half-paid and half-good treatment and each month, doctors received half-wages of 160 to 200 leva, i.e. German Marks. There were frequent cases when communes were unable to secure financial resources for their medical workers for months.

As of July 1, the doctors will receive their salaries from the Health Insurance Treasury (NZOK) which will be collecting these resources from the citizens' insurance contributions. For their part, citizens will have the right to choose their own doctors and dentists. "The aim is for both sides to find their interest in this. A patient will be able to choose his personal physician and demand the best possible health services. And doctors will have to provide good-quality services in order to keep their patients, perform check-ups and get money for that service in return". This is how Ilko Semerdzijev, Health Minister, explained the meaning of the reform.

General practitioners will receive salaries from NZOK according to the number of registered patients. Additionally, each patient will have to pay 1 percent of the minimal worker's wages (DM 75), for each medical examination. The physicians are under the obligation to be available to their patients 24 hours a day. In case the treatment is above his possibilities, a general practitioner will refer a patient to a specialist. For the time being, hospital care will remain free-of-charge.

In order to enable the normal beginning of the private practice, NZOK has advanced resources for the following quarter. In this way for example, a doctor caring for some 2,000 patients will be able to receive between 5 and 6 thousand leva, with which he will have to cover costs of starting the private practice, procuring medical equipment and renting surgery space.

Fear of failure

As usual, the road to good intentions is not paved with flowers. As it could be expected, the fear of anything new and inertia from the past, have put the reform ideologists to the torture. Despite numerous propaganda campaigns, only 50 percent of the population chose its family doctor by the end of June. That means that from July 1, as many people will not know which doctor to see in case of need. This will affect the doctors most because they are counting on the money that they will receive for each patient that registers with them.

However, the gravest problem is whether this health insurance treasury will survive. Created on purely economic principles, it is replenished from patients' contributions and can pay out only as much as it receives. Health insurance agencies were supposed to start sending the money to the NZOK account already a year ago, but many Bulgarians and their employers do not pay the compulsory insurance.

Two months before the start if the health reform, it turned out that the NZOK funds will not be sufficient. The treasury management even asked for the doubling of monthly instalments - from 6 percent to 12 percent of monthly income. For the time being, the stability is guaranteed by the World Bank loan, but there is a possibility that the system will not be able to meet the challenge.

The depleted accounts were also the reason for restricting the number of free-of-charge services. This will further increase the distrust of the Bulgarians in the success of the reform because they are used to having all types of medical services free-of-charge. For example, dentists will not receive funds for registered patients, only for performed examinations. But the National Treasury can pay them only 21 hours of work per month (!) - which is some 23,50 leva per hour. A dentist should see a patient for whom he has made an appointment within three month period when services which are paid from health treasury are in question. It is still not clear what kind of service package will each patient have the right to get free-of-charge, but it is expected that it will comprise a few fillings or extraction of 1 to 2 teeth. Most of the services will have to be paid for.

Scandals

Maybe the patients would have had a chance of receiving a larger package of free-of-charge services were it not for the bragging of the NZOK chiefs. Even before the reform started they spent a large share of funds for other purposes than those specified. Discovery of the misappropriation of funds was a blow to the image of the broadly advertised changes and the Social Accounting Service and the Parliamentary Commission "Anti-Mafia" have been entrusted with studying its dimensions.

It turned out that a number of "Renault Laguna" cars that were bought with that money are nothing compared to the funds used for offices all over the country. Purchase of buildings at very unusual prices, conclusion of suspicious contracts on the purchase of equipment and luxury repair works with terracotta tiles, aluminium profiles and hanging ceilings - are just some luxury items which NZOK spent money on in 28 district centres all over the country.

Chief of office in Pazardzik is already under investigation for the committed abuses. Already last year a doctor - psychiatrist amazed his fellow citizens by the ease with which he was spending public funds. Among the most striking examples are two seminars which cost 2,000 leva each or better said the doctor's skill of managing to be at two different places at the same time - at an official lunch for 300 leva and on a business trip to Sofia (according to travelling papers for the used service car).

Chiefs of office in various towns decorated their offices of the local health treasury according to their ideas and tastes. And each incurred enormous costs. Incidentally, the available resources are insufficient to cover a larger package of services for patients.

In such a situation it's no wonder the level of paid-in social insurance contributions is not very high. This question is directly linked with the confidence of the society at large, in the health reform. And how could people have any if the money has been already spent on numerous repairs even before the doctors started treating them.

Georgi Filipov

(AIM)