HEALTHY HEALTH SYSTEM?

Three different health ministers in little more than a year and health care reforms that are constantly postponed and heatedly challenged. A national health insurance authority which is the focus of investigations into more than 300 million leva in missing budget allocations and hospitals on the verge of bankruptcy. Even if you have had no immediate contact with the Bulgarian public health care system, the news that you hear daily can hardly be a comfort.

But you never know. In Bulgaria the economic crisis rages on, and if you are somehow involved in the country's economy, you might be well advised to find out if you are eligible to use public health services – if not for actual treatment, at least to get a reduction on prescription medicines – and if you are, then how to go about it.

The first thing to find out is your status. NZOK (www.en.nhif.bg/web/guest/home), Bulgaria's statutory health insurance fund, distinguishes between two categories of foreigners.

The first includes all refugees and those who have permanent resident status in Bulgaria and are not citizens of the EU, Iceland, Norway, Liechtenstein or Switzerland. They must have health insurance with the NZOK, which gives them the same health care rights as Bulgarians.

The second category consists of tourists and citizens of the EU, Iceland, Norway, Liechtenstein and Switzerland who are based in Bulgaria for an extended period. They must have health insurance in their own country and hold a European Health Insurance Card, or EHIC.

If you meet none of these conditions, you must pay for all medical services that you receive at public hospitals, just as you do at private practices. An exception applies for emergencies and in cases of mandatory hospitalisation, which may be ordered during outbreaks of acute contagious diseases. Maternity services are also free.

If you are entitled to public health care in Bulgaria and you want to access it, you should be prepared for a certain amount of paperwork.

If you reside in Bulgaria permanently, you are obliged to register with a GP who has a contract with the NZOK. Your GP is the first person you turn to if you have any problems and they also coordinate your mandatory annual health checks. (Failure to undergo one may cost you up to 500 leva.) Your GP can order lab tests and he or she is the person who decides whether to refer you to a specialist.

In this context, the word to remember is napravlenie. This is a clinical pathway note issued by your GP, which entitles you to an examination by a specialist or to hospitalisation, without paying a fortune. If your situation is not an emergency, you are better off visiting your GP at the beginning of the month. GPs may only issue a fixed number of napravleniya per month and quite often use up their allocation before the end of the month. Another thing that's worth knowing is that you can change your GP twice a year: between 1st and 30th of June and again between 1st and 31st of December. To do so, just visit your new GP and sign a declaration. You must also bring your health insurance book with you.

Public health care is not entirely free. Each time you visit a doctor or a dentist, you must pay a fee, which is fixed at 1.0 percent of the national minimum wage, or NMW. For 2010 the NMW is 240 leva a month, which means that you will be charged 2.40 leva. (Do not forget to insist on a receipt.) If you're hospitalised, you are charged 2.0 percent of the NMW a day, or 4.80 leva. This applies for 10 days in the year, but some patients – for example, women giving birth and cancer patients – are exempt from payments. You are also charged 1.0 percent of the NMW for lab tests.

Your GP is the person to turn to for a prescription for NZOK-paid medicines. If you have a chronic problem, you must also have a prescription book, a document in which your GP describes the nature of your ailment. You must then have the book registered with the regional health insurance fund that serves the area you live in, and then you can buy your medicines. You do this at any pharmacy that has a contract with the NZOK. Such pharmacies are easy to recognise: they have the NZOK logo on their front windows, as well as signs such as "This pharmacy is partnered with the NZOK."

If you need dental care, make sure you register with a dentist who has a contract with the NZOK. Dentists may prescribe further treatment as well as further tests by issuing a napravlenie.

Citizens of the EU, Iceland, Norway, Liechtenstein and Switzerland are entitled to the same health and dental examinations as Bulgarians, hospitalisation included. They need, however, to handle a heftier load of paperwork.

The first thing to do is choose a doctor or a dentist who has a contract with the NZOK. You must then make two photocopies each of your EHIC (or comparable document) and of your ID. When you go to your doctor, they will check your EHIC and ID, fill out a form with the data, and keep the photocopies. Then you must sign a declaration in Bulgarian, English, French and German stating that you have not come to Bulgaria as a medical tourist.

Only after these formalities have been attended to can an actual examination begin and, if necessary, a referral to a specialist issued. You will be charged the same fees as Bulgarians who have health insurance. The red tape show continues for the doctor, however. They are obliged to submit to the NZOK the form with your personal data, the copies of your EHIC and ID, your I'm-not-a-medical-tourist declaration, and an invoice that itemises the procedures you have undergone. They must also notify the NZOK when you are hospitalised.

This complicated procedure is largely why there is an absence of precise data in Bulgaria recording how many foreigners use the public health services or visit the country as medical tourists. "The doctors simply do not provide the necessary information," a source at the health ministry said. The NZOK told us that "in principle statistical data should be kept; however, we can give you none."

Can you get health care if you need it and are entitled to it, but have no documents to prove that you are? In theory, yes. You will be admitted to a hospital and will receive treatment. The NZOK will then contact your health insurer in your own country, which completes the documentation. If time is short, however, you will have to pay the NZOK the full amount for your treatment, and then seek reimbursement from your health insurer.

If you have a chronic illness and your stay in Bulgaria exceeds a month, you have the right to buy medicines at reduced cost or receive them free of charge, if their cost is covered by the NZOK. In such a case, the NZOK recommends that you register temporarily with a GP, who will issue you with a prescription book that you can use to buy the medicines.

Perhaps you have already been asking yourself questions such as how do I know which doctor or dentist to go to if my Bulgarian is limited to the vocabulary needed to order a beer in a restaurant? How can I find out who speaks French, English or German when I haven't been to all the GP practices at the nearest clinic and haven't spoken to the doctors there?

Such concerns are pertinent but it seems, however, that nothing can be done about them. The Health Ministry told us they did not know how to go about this and referred us to the Bulgarian Doctors' Union, or BDU, and the Health Information Centre. The latter did not answer our written inquiry – the only form of communication that it recognises. The BDU had no idea where information could be found about doctors who have NZOK contracts and speak a foreign language. We were referred to BDU's Sofia branch. However, our calls there were not returned.

All this explains why our efforts to find an expat who uses the Bulgarian public health service have hit a dead end. "No one has ever bothered doing this," was the direct answer we got from someone who firmly believes that, in Bulgaria, private health care is the only route to take.

With the support of the Trust for Civil Society in Central and Eastern Europe and Open Society Institute – Sofia