Bulgarian health care is up against a number of challenges, including an imbalance in the types of staff leading to a nurse shortage and issues with funding, putting the health of citizens at risk.
Bulgaria had the second highest death rate per capita during the COVID-19 pandemic, second only to Peru, despite the official state statistics pointing to Bulgaria being third in the EU in terms of the number of beds for hospital treatment.
While the country is home to 340 hospitals for a population of 6.5 million, ranking it in the top three in the EU regarding hospital beds, a staff shortage is hampering the situation resulting in the third highest mortality rate in the EU, at 21.7%.
“Beds and medical devices do not heal patients. This is what doctors do,” said Ventsislav Mutafiyski, head of the Military Medical Academy in Sofia, one of the largest Bulgarian hospitals.
Bulgaria currently has 29,604 doctors and 28,816 nurses- figures that differ from the European norm, which usually sees more nurses than doctors in national health systems.
A ‘severe’ nurses issue
According to Eurostat, the ratio of nurses to the population is the lowest in the EU – 6.9 per 100,000 people, with one-third of working nurses over 65. Ireland reports that 1.6% of the population are nurses, and in 10 other EU countries, the share of nurses is at least 1% of the population.
In the 1990s, at the start of the democratic transition from communism to a market economy and democracy, there were 28,000 doctors and 53,000 nurses in Bulgaria.
The number of nurses has almost halved since then, with a 9% drop over the last ten years. While there has been a slight decline in the number of doctors, it is not as concerning as that of nurses and has been somewhat mitigated by an 11.5% population decrease over the last 30 years.
The decline of medical professionals was particularly sharp after 2013 when the restrictions on access to EU labour markets for citizens of Bulgaria and Romania were removed, and many went to work abroad.
Research by the Institute of Market Economics (IMP) notes that 2020 also saw a sharp drop in numbers due to the pandemic, risks to elderly staff, and harsh working conditions.
IMP commented that for the optimal functioning of the health system in Bulgaria, the nurse-doctor ratio should be at least two to one, still a far cry from Finland, Luxembourg, Ireland, Switzerland, Iceland and Norway, where the balance is over four to one.
The dwindling numbers make providing two nurses per shift in hospitals impossible, meaning there is often just one nurse to take care of over eight patients.\
In response to EURACTIV’s query, the Health Ministry reported that the biggest shortages were in emergency medicine, internal medicine, general and clinical pathology, infectious diseases, paediatrics, epidemiology of infectious diseases, general medicine, and otolaryngology. There are less than 70 forensic doctors and roughly the same amount of pathologists.
The number of general practitioners is decreasing, and the workload is increasing. At the same time, and despite the increased budgets of the Bulgarian state health fund, Bulgarians pay up to 40% of the health services they use. This is almost twice the EU average.
Beyond any standards
One of the main drivers behind the issue is believed to be related to salary. Nurses in Bulgaria have an average monthly wage of €450-€1,000. Public hospitals are the most reliable employers, while private hospitals have no regulation, according to Nadezhda Margenova from the Union of Bulgarian Medical Specialists (SBMS).
She told EURACTIV that there are options for nurses to increase their income, but not all are viable.
“One option is to change their workplace – the so-called professional tourism. The other is to take on extra shifts, to have a second and third job, which worsens the quality of life and work. To bring in additional funds, colleagues do it without observing the mandatory rest after 12 hours on duty. The second option is making a life decision to leave the profession or to emigrate,” said Margenova, a nurse herself.
Dr Stoicho Katsarov from the Centre for the Protection of Rights in Healthcare and a former health minister commented that the solution is to limit the state intervention that has led to most of the problems.
“Countries that have market-based health systems responded better to the COVID-19 pandemic,” he said. “The state distributes the money, regulates almost everything and thus has limited competition. It sets limits for the hospitals, which are practically their budgets, and the hospitals strive to absorb them, and no one is interested either in the quality or whether people are actually treated in them,” said Katsarov.
According to him, salaries are determined by the market. Therefore, any attempts by the state to introduce a basic wage for doctors are not advised.
The lack of a career development system was noted by Dr Vanyo Sharkov, who is a former deputy minister of health. Speaking to EURACTIV, Sharkov stated that it is necessary to distinguish funding, and more funds should be available for those medical facilities that provide quality medical care, including emergency medicine.
“At the moment, Emergency Services in Sofia transports patients to two or three medical facilities that receive less funding than medical facilities that do not have an emergency department, and since all hospitals – both public and private – are financed on the same principle, then they must have emergency departments as well,” he said.
To date, no political party has proposed solutions to the problems in the health system, including and about the shortage of personnel.
(Emilya Milcheva, Krassen Nikolov | EURACTIV.bg – Edited by Alice Taylor)
