Банкеръ Weekly



Nowhere else have I seen as badly organized emergency aid as the one I see in Bulgaria... Professor Radoslav Gaydarski, Minister of Healthcare, made that confession in Plovdiv recently in support of the measures taken for improvement of the First Aid organisation with so many years of delay.
It's a pity that changes in the health sector are being made without coordination. Patients are growing dissatisfied with the level of services they get and medical experts - with the huge gap in remuneration among different levels in the branch. After general practitioners and pre-hospital experts have been widely discussed, hospital institutions with their millions-worth debts and insufficiently funded clinical paths have been the new hot topic in the past two or three years. However, nobody seems to have thought of the emergency aid in the meantime. Now it obviously lacks its first seven years of health reform. And it was exactly casualty wards and their staff that bore many of the hardships of transition. They became the cushion of GPs who kept grumbling against the 24-hour readiness the law came to impose on them. Besides, ambulance teams remain one of the fastest and easiest ways for people to be admitted to hospital, even for those who haven't made their health insurance payments. When they are used, there is no refusal. No talons, no reservations.
In fact, ideas about reforming the emergency aid wandered for a while in the minds of clerks in 2000. At the time, even ambulance drivers had to pass a special training course for medical assistance. According to witnesses of the processes in the past, however, all plans were forgotten after 2001, including the annual courses schedule. Then, dequalification of the staff began...
There was a strategy for restructuring emergency aid that was discussed by the former government, Dr. Vanyo Sharkov recalls. Before he entered the parliament from the United Democratic Forces group, he presided the emergency centre that served the Sofia region. Thanks God, it had been forgotten, because it stipulated that only paramedics would work in the first aid.
Another persistent problem of the system has always been the turnover among doctors. Nobody is quite willing to do exactly this type of work, people from the branch told the BANKER weekly. Most of the staff employed in emergency service has just graduated and as soon as it finds another job, it quits. The reason is not the hard 12-hour duty or rebukes by patients and their relatives. The explanation hides in the salaries which are the lowest ones in the entire branch.
The healthcare ministry now reports that in most of the 188 existing emergency affiliates it is the medium medical staff that takes up the major work burden. This results in slower operations, worse quality, frequently hyperdiagnostics and subsequent extreme expenditure on medicines and medicinal products. It will take efforts and time to change this situation. However, having found out the lack of coordination and collaboration between First Aid and the other units of the health system, the authors of the new health strategy proposed something that was new for Bulgaria.
The first strategic proposals have been realized in Sofia by July 1 and in Plovdiv - by July 26. They refer to the moving and settling of emergency teams in densely populated quarters which react quickly and adequately in providing medical assistance when they are called. In Sofia, there are already 13 ambulances that do not stay at their base at the Goods Station, but are based next to diagnostic and consulting centres and hospitals throughout the city. Following one-month practice, the head of Sofia Emergency Medical Aid Centre, Dr. Georgi Gelev, himself confirmed the efficiency of the changes. Time for arriving to an address has been shortened by 15 to 22% and in most cases we arrive in 10 or 15 minutes now, he told the BANKER weekly. However, because of the lack of a sufficient number of teams we keep sorting the calls by emergency. We would have reacted to each call immediately if we disposed of more than 50 teams, as it should be, and not 20.
According to Dr. Gelev, if Bulgaria succumbs to other countries in the service of emergencies, it is just because of the insufficient financing and the lack of equipment. According to the world standards, 10% of the consolidated healthcare budget is usually provided for urgent assistance in the ambulance (not in hospitals). If this was applied in Bulgaria, too, First Aid should have BGN200MN at its disposal in 2006. However, budget for the ambulances is about four times smaller now. The amount for the country is BGN47.726MN and for Sofia it is about a tenth of this sum, even though the structures in the capital city serve 25% of the Bulgarian population.
The model of organisation is not revolutionary, but its edge consists in the fact that it does not require extra money and will probably be applied in other larger towns, too. Such change in the ground of urgent teams is also existing within several municipalities, the healthcare minister informed during July's last parliamentary control session. Although emergency affiliates are based in neighbour towns, ambulances are on duty in Shabla, Blatsigovo, Yakoruda, Lyubimets.
A more radical reform will be the transfer of wards which are now at emergency centres towards the respective hospitals. Most often they are situated in one building and when a patient is driven apparatuses and consultants from the hospital are used while they are not given any money for it. After the restructuring the centres will keep their logistic activities, while treatment will be undertaken by the respective hospitals.
However, this reasonable solution is difficult for implementation not just at first sight. It relates to the appointment of more staff to medical institutions so that 24-hour duty of medical teams can be secured. Yet the greater number of officers will require more money for remuneration. Therefore, regional hospitals with casualty wards may some day look like Pirogov hospital not only in operations but also in reduction of the salaries.
As we know, it was the biggest emergency hospital that reminded us of another paradox in the Bulgarian healthcare sector which resulted in doctors' protests in July. It is strange indeed that in the very first month following his appointment at top of the healthcare ministry prof. Radoslav Gaydarski announced that emergency aid would be a priority in 2006. At the same time, at the beginning of 2006 it turned out that the officers in the ministry forgot to plan financing for approximately two million emergency patients who were served but not hospitalized. The discontent of the Pirogov doctors abated due to promises they would be paid for their work. At present, though, money can only be provided by the emergency aid budget which is already quite insufficient.
One more example for the painfully difficult introduction of every change in the healthcare system is the single emergency call number 112 which has been planned for years. It is a subject of confrontation between the Ministry of Interior and the Ministry of Disaster Management Policy and although BGN14MN have been provided for the purpose, Bulgaria will not reach Europe in this aspect until 2013.
Let's hope the number of people dying as a result from ambulances arriving too late falls down by then at least. The moved emergency teams in Sofia and Plovdiv are already making efforts in this direction, but because of the lack of enough money for the system most doctors remain sceptics. We are trying to save Titanic from sinking by rearranging the furniture on it. This is not going to work, they snapped.

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