National Report of The Bulgarian Medical Association http://www.blsbg.com/
to the General Assembly of FEMS, 12-13 June 2009
Labour Conditions of doctors and some tendencies in Healthcare in Bulgaria for 2008/2009
Dr. Konstantinov, vice chairman of BuMA
Dear Colleagues,
“Reforms” and “changes” were frequently spoken of but not present of actual fact during 2008. The status of the sector in the part concerning the doctors is characterized by the following basic items:
1. Low percentage of public expenses for Healthcare. They amount 4.2% of the gross domestic product (GDP).
2. In the last 3 years nearly all decisions for Healthcare were taken one-sidedly, without the participation of BuMA. The most illustrative example is the lack of a Framework Agreement between the National Health Insurance Fund (which distributes the financial resources for all health-insured citizens) and BuMA (members of which are all the Bulgarian doctors). This agreement describes health-economical, financial, medical, managerial, information and legal-deonthological frames according to which the individual agreements between NHIF and medical healthcare providers are contracted. Though by virtue of the law negotiations should be held annually an agreement hasn’t been signed since the end of 2005. Instead, the NHIF changes one-sidedly basic regulations in the work with the healthcare institutions according to its own views.
3. Healthcare in Bulgaria is characterized by wide bureaucracy that reaches the doctor-patient level. The doctors are wasting more and more of their time being coerced into both paperwork and processing administrative requirements. This happens in spite of the introduction of the information technologies which in most of the cases do not rescind the old forms for report on activity. The frequently changed requirements become reason for documental omissions that lead to formal sanctions. Thus doctors are punished for documental omissions, not for bad medical practice. This leads to limitation of their autonomy because more and more they start to take into consideration the requirements of administrative instructions instead of the medical ones.
4. The salaries of the hospital working staff remain comparatively low. This is due to insufficient update of the prices the hospitals are paid by NHIF. Since the beginning of 2006 the increase is 10% which is notably below the inflation increase for the period. Precise record of doctors’ remunerations is not publicly available but according to the Collective Labour contract for 2008 the minimum basic doctor’s salary should be no less than 530 BGN (272 EUR). Even this minimum starting basic salary is not provided by all healthcare institutions, at that – for doctors with specialty and considerable practice.
5. A considerable margin in the remunerations can be witnessed regarding doctors with different specialities or with one and the same speciality but working in different hospitals. According to publications in the press, in some cases the margin measures up to 20 times. These differences are due to imperfections of the ways of payment for the hospital cares, lack of criteria for calculation of the price of the clinical path (the funding tool chosen in Bulgaria), differences in the work scope. Most of the clinical paths are partially paid while others are comparatively well paid which reflects on the income of the doctors who practice them. Why though there is general discontent there are yet no united protest actions can be somewhat explained by these great differences.
6.The low price the hospital care is paid is the stepping-stone to two basic effects:
- Increase of hospitalizations on a national scope. The hospitals seek to preserve their income level by raising the patient turnover. Fighting this NHIF strives to counteract by introducing various restrictive mechanisms some of which infringe upon the rights of the health-insured while others infringe upon the good clinical practice.
- Emersion of different forms of co-payment on the part of the patient which is legally prohibited for activities funded by the Insurance Fund. Most often the co-payment is committed under the guise of ”team option”, payment for consummation accessories or a downright cash payment to the healthcare providers. The last one has already provoked some demonstration actions against doctors receiving money from patients in non-regulated ways. This creates negative dispositions against the profession as a whole.
7. In order to make up for the low remunerations at the hospitals the majority of the doctors are coerced into extra work on additional labour contracts or in private consultation/surgery offices. Thus their working day goes greatly beyond the generally adopted 40 hours a week.
8. Duties at night and in the weekends aren’t actually paid with extras (with the exception of the national holidays), and are included in the general monthly work-schedule. Time at call is not taken as working time and is paid just as token.
9. Doctors have no privileges in case of illness – no free medicaments or tests, not even partially.
10. Against the background of evident failures of the state to solve basic healthcare problems such as the large number of non-insured people (1 million in comparison of a population of 7 millions), poor collection of insurance fees, partial payment of medical activities, corruptive and lobbying practices at the re-distribution of public funds, the administrative and bureaucratic control on the doctors in the country is increasingly intensifying. A case in point are the recently adopted amendments in the Health Law which create an Executive Agency within the Ministry of Healthcare assigning exclusively broad duties for control and sanction to it. Doctors express fears that this Agency would not only duplicate the work of a number of now functioning controlling bodies but could also be used for political repressions of the doctors. BuMA sharply opposed against the way of its formation and assigned duties. We trust in and look for the backing of our European colleagues in the fight for our professional independence.
11. Young doctors turn to work in pharmaceutical companies or go abroad where the remunerations and labour conditions are better by far. During the period 01-31.01.2008 BuMA has issued 105 certificates for colleagues who are preparing their documents to work abroad. For the same period of the current year their number is doubled to 203. The average age of the doctors is rising. Already there is open insufficiency in a number of specialties such as anatomical pathology, infectious diseases, anesthesiology, pediatrics, etc.
12. In 2008 BuMA endured an inner drama relevant to the refusal of the old governing body to convoke the regular Report-and-Elect convention. Such was fixed in January 2009 after amendments in the Law which regularizes the foundation and duties of BuMA. Despite the great difficulties with the transference of governance the current BuMA governing body is working towards recovery of dialogue with all institutions and the best possible defense of common interests of Bulgarian doctors by all legal means.