NATIONAL HEALTH DISSERVICE

A month ago I visited a friend in Sofia's Pirogov Hospital. The following day he was due to undergo a partial leg amputation just below the knee. My friend had been suffering from diabetes for 47 years. Apart from that, he had enjoyed good health. He lives in a beautiful house in Burgas, where he is always surrounded by friends.

I entered the Septic Surgery Department of Pirogov, an “elite” state hospital that treats some of the most difficult cases in the capital and the country. My friend was sitting up in bed, as cheerful as ever although the setting was the polar opposite of his Burgas home. It looked more like a First World War field hospital.

Patients were clenching their teeth in pain, lying on filthy sheets. Large cockroaches scampered over the tattered walls. The room reeked of that awful combination present in many Bulgarian state hospitals: musty air, badly-cooked food and toilet stench. Like other state hospitals, there is only one bathroom on each floor of Pirogov. Its door is always open and it's never well-cleaned.

My friend knew he would undergo the amputation the following day. He didn't know whether this would save his life, because doctors had not explained his condition to him. Neither had they clarified the stages of post-operative care. However, he wasn't particularly shocked by these oversights. Why? Because he was there due to medical negligence in the first place.

When he found a small wound on his leg, my friend immediately consulted a doctor because such injuries heal less easily in diabetics. The GP prescribed him some homeopathic (!) medicine. The wound grew and an infection appeared and spread. But the doctor still did nothing. Then my friend's wife decided they should travel to Sofia. Unfortunately, it was too late. After several weeks of pointless examinations, my friend ended up in Pirogov, the only hospital in the country with a special septic surgery department. There he was told that he needed a partial leg amputation.

My friend was anxious to undergo the operation because he found the atmosphere in the septic ward depressing and when I visited him again the next day little did I suspect that he was about to leave Pirogov with undue haste. Just two days after going under the knife, he was discharged. But he was unprepared to leave so quickly. His amputation stump was not properly healed and nobody had advised him on how to use the crutches that were indispensable to his mobility. However, perhaps my friend should have counted his blessings. At least the staff at Pirogov had agreed to operate on him without asking for a bribe!

This is not an isolated case. Poor conditions are the rule rather than the exception in Bulgarian state hospitals. And in case you think this is a particularly bad example, we should warn you that hospitals outside the capital are far worse.

The causes can be traced back to the Communist era when, in theory at least, all citizens were entitled to free medical treatment. Indeed, any nostalgically-minded Bulgarian will tell you about the time when medical examinations and dentistry were free. But what they don't tell you (people tend to have rose-tinted and selective memories) is that “free” Communist health care was actually very expensive. Hygiene was a flexible term, equipment was old and unreliable and staff were as rude to patients as they are now. Their attitude changed only after a little “inducement”. This took the form of a bottle of expensive cognac, a box of chocolates or some other favour (planned economy had turned the procurement of everything from wall tiles and good coffee to a Rolling Stones record into valuable commodities for exchange).

The Communist hierarchy viewed the population's health in the same way they viewed the nation's beautiful countryside – as a feature of life that required little maintenance. Authorities manipulated data about medical standards. Vital drugs were, theoretically, available, but in reality scarce.

After 1989, “free” health care went bankrupt along with Communism. Uncensored reports suddenly appeared. Bulgarians, to their horror, discovered they actually topped the European “league table” for cardiovascular diseases and cancer. Suddenly, medicine had become a costly necessity and health care turned into a complex market-type system.

In the first nine years after the changes, politicians delayed much needed improvements in public health care – just like other reforms – hoping that the situation would somehow rectify itself. This triggered the crisis of 1996, the kind of calamity that normally happens only when a country loses a devastating war.

Restructuring of health care, on market principles, began as late as 1999. The government of the United Democratic Forces established the National Health Insurance Fund (NZOK) and levied compulsory health insurance at 12 percent. They also introduced general practitioners, or dzhipita, as they are known by the Bulgarised version of the acronym. To avoid the establishment of fake private health funds, which stole patients' money, NZOK retained a monopoly until 2001. After that many hospitals should have been privatised and inefficient units closed down.

However, reform was fraught with inevitable problems. Staff in private units faced vast administrative duties. They also faced a lack of specialist doctors and hospitals for patients' referrals. But the system caught on and good GPs began earning high salaries.

Sadly, the situation in state-owned hospitals hardly changed and by 2001 the reforms had stalled. Many hospitals remained registered as commercial companies and accumulated debts. Nobody dared to step up health insurance contributions. Alternative health insurance funds did not emerge either. The NZOK lost its public status and fell under the auspices of the Ministry of Health. The actions of the government of the Bulgarian Socialist Party, elected in 2005, worsened the situation further.

Consequently, many medical workers have emigrated, the quality of health provision has deteriorated and 1.5 million Bulgarians cannot afford to or will not pay their health contributions. Given the existing corruption in state hospitals, they see no reason to do so. So-called unregulated payments have now replaced cognac and chocolates. These “voluntary donations” mean that patients may have to pay anything between 20 and 70 leva for a medical examination. The cost of an operation may exceed 1,000 leva. According to some reports, this kind of bribery amounts to about one billion leva a year. Indeed, health constitutes a large part of the country's “grey” economy.

Official state investment in health is scandalously low. Average annual health expenditure in Europe is 1,700 euros per capita, but in Bulgaria it's a mere 130 euros. This, naturally enough, undermines the quality of the service. Here we should also mention one of the great problems with the state system – the lack of free medication for those with acute illnesses.

There has been a deficiency of vital medicines for years. In particular, cancer patients have constant problems accessing suitable drugs. In fact, most state hospitals have adopted an unwritten rule – they ration the use of such medicines to people under the age of 50. Unofficially, there are about a quarter of a million cancer sufferers in Bulgaria and the inadequacy of their care inevitably rebounds on their longsuffering families.

Many patients face a bleak future not only because of a lack of medication. There is still no solution to the problem of caring for severely sick people. Many state hospitals habitually discharge patients much too quickly, either due to bed shortages or because the treatment on offer has ended. There is also a lack of home care nurses. In any case, most ordinary Bulgarians can't afford their services. Hospices for the terminally ill are virtually non-existent. So it's left to family members to care for sick relatives themselves. It's not unusual for relatives to adopt the role of medical personnel for months – even years – and this exacts a painful toll.

What are the politicians doing about it? Nothing. For them, there is the specialised Government Hospital in Sofia. This continues the Communist tradition of providing fast, quality and totally free medical services for them and their families. But if an “ordinary” health-insured Bulgarian attends the Government Hospital, he will have to pay in the same way as in a private clinic.

State health care in Bulgaria is a fight for survival. Your only weapons are money, “connections” and fast reactions. If you must resort to it, bear in mind the following important guidelines.

If you have a choice, go to a hospital in Sofia, or, alternatively, Varna or Plovdiv. Enquire about the best doctors in the respective fields and how you can get quick access to them. Don't take risks with just any doctor. Consult at least one other expert regarding your diagnosis. Beware, however, that this can be a double-edged sword because you may end up with five different (and inaccurate!) diagnoses from five different doctors. Don't just rely on doctors to keep you informed. Insist on knowing every aspect of your treatment. Remember that state hospitals like the word “operation” – even when it may be unnecessary. Try to learn more about your condition to avoid being manipulated. And take note – in a state hospital your health insurance does not mean you won't be asked for a bribe.

There are, of course, exceptions. My friend was luckier than most. He got no particular courtesies but neither was he regarded as a hen laying golden eggs. So there is no way of disguising the fact that your treatment is unpredictable at best. This is why you should try to stick to a simple rule: avoid ending up in a Bulgarian state hospital. At all cost. Unless you're willing to take your chance in a very dirty and hazardous jungle.

CRUEL AND CALLOUS
by Jean Hayes, A Vagabond reader in Gabrovo

I recently had the misfortune to trip on broken pavement and break my leg just under my hip bone. Consequently I spent two and a half weeks in a Gabrovo hospital. I want to share my personal experience there as I feel that people should know what to expect if they are hospitalised.

The surgeon was excellent, the operation went well (there shouldn't even be a scar) and the theatre and intensive care ward were very modern. However, having said that, there was a problem with the foot, which had got trapped in the pavement. This was ignored despite my telling them about the continual and sometimes agonising pain. On my last day they realised it was a real problem and summoned a neurosurgeon who prescribed urgent treatment.

I am alone in the country and didn't have the EU health insurance card or private medical insurance. The total fees amounted to 2,800 leva, which I was supposed to pay before they would operate. They eventually operated when it was confirmed that money had been transferred from England. It had to be in cash – this was also a problem as I couldn't go to a bank. In addition, my prescription charges on my release have now amounted to nearly 550 leva. The British Embassy in Sofia said they thought I could claim the fees back from the health department in England.

The conditions and aftercare were appalling at times. There were no curtains around the beds so there was no privacy for anything at all: examinations, toilet needs or changing clothing. The lack of privacy for bedpan use and cleansing requirements afterwards – and the indifference of many of the nurses in this respect – were particularly distressing. A very limited amount of food is supplied for breakfast and lunch and then nothing more. So you really need good friends or family here. The food gave me diarrhoea as it was nothing I would normally eat and, naturally, this didn't help my situation.

I was confined to bed and there were no personal hygiene facilities until I insisted on some water and a bowl in order to brush my teeth and try to wash. Wanting to do so was regarded as quite amusing.

Money for equipment is clearly lacking. But many of the staff seem to forget the fact that patients are people and not just lumps of meat on a production line. Nursing is supposed to be a caring profession. I was in pain much of the time and had to ask for medication that was eventually reluctantly administered. I realise that staff are very poorly paid but at times the treatment I received was nothing short of cruel and callous.


HOW THE SYSTEM WORKS

There is a simple regulation: even though you have paid your health insurance, you also have to pay a “consumer fee” to every medical worker you meet because of your illness.

When a Bulgarian citizen has health insurance, he chooses a dentist and a GP. The GP is the first person he turns to if he needs medical help, after paying a consumer fee equal to one percent of the minimum national monthly salary, which is 200 leva at present. The difference between it and the real cost of the examination is covered by the NZOK. When the GP considers it necessary, he gives the patient a referral. With it, he can go to a specialist or enter a hospital that has signed a contract with a Regional Health Insurance Fund. For certain illnesses, decided by the NZOK and the hospital, there are so-called clinical paths and the cost of their treatment is covered by the NZOK. In this case the consumer fee, paid by the patient, is two percent of the minimum salary for each day spent in hospital. If his stay exceeds 10 days, he no longer has to pay.