QUALITY IN HEALTHCARE IS A RELATIVE CONCEPT AND VERY DIFFICULT TO MEASURE

Dr. Nikolay Branzalov graduated from the Medical University in Plovdiv and specialized in internal medicine, general medicine and health management. He has been working as a general practitioner for 24 years. He has been the Deputy Chairman of the Board of the BMA for two consecutive terms (2018-2024), and since September 2024 he has been the Chairman of the professional organization. He is also Deputy Chairman of the Capital Medical College and Deputy Chairman of the National Association of General Practitioners.

Health was highlighted as a priority in the regular government's agreement. Do you expect that actions will follow to help increase its effectiveness? What should they be?

Health care cannot fail to be among the priorities. Unfortunately, the unstable political situation in recent years and the lack of a horizon do not bode well. The health sector does not tolerate abrupt changes and rapid reforms; a clear and consistent policy and continuity are needed in order to be able to enjoy good results over time. Recently, a survey showed that the absolute priority for Bulgarians in Budget 2025 is healthcare. A majority of our compatriots - 57% - are of the opinion that the most significant increase in funds should be for healthcare. It is a priority for absolutely all social, demographic and electoral groups, and only for people over 65 it is displaced by the desire for pension growth. Against this background, what we have seen so far does not give me cause to be optimistic.

In the draft budget, there was a text that introduced restrictions only on the activity of hospitals. Such a measure, on the one hand, is discriminatory and, on the other hand, it cannot fulfil its objective of restricting consumption, because all it proposes is to reduce the funds for healthcare providers. And at the same time sits the requirement for mandatory remuneration. This is the place to remind you once again that since the creation of the Health Insurance Fund, limits, regulatory standards, estimated budgets, etc. have always been introduced only for medical activities and never for medicines, medical devices, etc. All this has led to nothing but service bottlenecks, patients waiting for an appointment or specialist and being charged extra, despite being insured. Automatic price reductions would not reduce the overspend. Such a mechanism is nothing more than a convenient way of creating a hidden deficit and forming the deceptive perception that the money is getting through. And against the background of the obvious shortage of funds in the system, it is proposed to introduce a new activity - the so-called biomarker testing, which will also draw funds from the hospital budget of the NHIF, in unknown amounts and without a mechanism for limitation. I hope that this will be cleared up between the first and second readings.

It is increasingly discussed by politicians and managers of municipal and state hospitals that medical institutions should not be commercial companies. Do you share their opinion?

For me, this is a very utopian model of existence at the moment and I don't think we can go back to it, and I don't think it makes sense. Medical establishments, whether they are commercial companies or not, are subject to financial, economic and accounting laws, and they cannot exist if costs exceed revenues.

In this question always lies the way of paying for the activity in hospitals, i.e. per passed patient. In the question "Should hospitals be commercial companies?" lies the sub-question "Should we be paid in this way, or should we go back to paying for structure rather than activity?". To the first part of the question, I would answer that it makes no difference whether it is a commercial company or a state-owned enterprise if it is paid for an activity, for a service provided. However, if it is paying for a structure, i.e. financing a building with staff, and it does not matter whether or not an activity is carried out there, then there are already other negative and, at the same time, positive aspects that we remember from more than 30 years ago. The truth is that then, compared to now, there was less staff interest in the patient... a complex topic that also raises the issue of valuing the work of doctors and health care professionals and the lack of clear criteria - how it is included, where, how it is valued.

After the Constitutional Court's decision, a complicated situation is created: on the one hand, the law restricts hospitals to work within the NHIF budget, on the other hand, there are no restrictions if they exceed it. What is the decision?

Largely in control, and in preventive control. Effective control in the system is necessary, and we have once again proposed that it should be carried out with the involvement of the patient. Every medical activity claimed for payment by the Fund must be verified by the patient, including the dispensing of medicines paid for by the NHIF. How this will be done is for the experts to say.

Should young cadres whose education has been cofounded by the state be bound by a commitment to work for a certain period of time in the country?

If it is related to informing these cadres in advance, there are other privileges: free tuition, accommodation, various social benefits and students know in advance that if you apply for a state order, you will have to stay and work in Bulgaria for a certain period of time - yes, we support this measure.

Is it the right policy to reverse the pyramid - more money going to outpatient care? Is there support for such action?

In recent years, this is exactly what has been happening, albeit with a delay - significantly more money is being given than before. We support and try to make constructive proposals for shifting the burden from hospital to outpatient care - of course, where it is possible and good for the patient.

Do you support the practice of introducing quality criteria in the National Framework Contract, not just quantity? Who should develop them? Should there be a price differential for clinical pathways on this basis?

We support in principle, but it is important to clarify that quality in healthcare is a relative concept and very difficult to measure. Whatever we try to set as criteria, they must be measured over a longer period of time and on a certain number of patients and, on that basis, the performance of the relevant unit in a given hospital or of the medical institution itself must be assessed. Quality criteria cannot be individual for a single patient because they are linked to many other conditions, both subjective and objective. The quality of the work of a medical institution is judged by objective criteria that are measured over a longer period of time - three months, six months, a year. The criteria can be specified by the scientific societies, by the NCHR, by the NHIF, but they cannot be for an individual. However, if you have a higher success rate, by objective criteria, over a longer period of time, then you are obviously doing better than other medical institutions. The criteria should also measure the severity of the condition in which patients are admitted - severe disability, chronic disease and then what outcomes are achieved.