How healthcare kills: lessons from neoliberal Bulgaria

Nоte from the LeftEast editors: Тhis article has been published in collaboration with the new Balkan web-portal Bilten.org. The publication in Serbo-Croatian is to be found here. 

In the last days of March 2014, a Bulgarian woman, Dobrinka Krumova, aged 26, died because neither private, nor public hospitals in Dupnitsa in South Bulgaria accepted her for treatment. A few years ago the woman was stabbed by her partner and father of her two under-aged children. After she parted from her partner and moved in to live with her retired mother, Krumova underwent a colostomy operation to survive the severe intestinal injuries from the stabbing. Ever since she had to use ostomy bags as the wound from the surgery wound never fully close. For a period of the last six months before her death the young woman had lost half her body weight. She also had to give up the custody of her two children and put them in orphanages because she had no money to take care of them: half the combined income of 150 euros of her unemployment welfare and her mother’s pension went for the ostomy bags alone. The rest barely sufficed for the two women to get by and so Krumova and her mother could not cover their medical insurance. It was a sum of 250 euros accumulated debt that made public and private hospitals in town refuse to give her a bed and medical care[i].

The news of Dobrinka Krumova’s death was only reported in a number of marginal regional media and started no public debate: her story is only an extreme case of a sad and silenced statistic of the lethal healthcare reform in neoliberal Bulgaria. While some countries never had free public healthcare, socialist Bulgaria had free service provided for all citizens. The partial privatization of free public healthcare since 1999 brought to Bulgaria the global trend of commercialization of healthcare, which turns human life and dignity into business. The medical budget started functioning as a state-controlled Health Fund to which each working Bulgarian had to contribute 6% of their salary in the form of tax. Due to high unemployment rates, high child-birth among the under- and unemployed, and an increased percentage of aging of the population, health-care benefits for almost four million Bulgarians were paid out of the taxes of just under one and a half million. Half a million have private insurance, and two millions remain out of medical insurance[ii]. Still, on average, Bulgarians pay for over 56% of their treatment out of pocket[iii]. Since the reform and given the souring situation, subsequent governments have annually redistributed further funds to fill in the gap. Yet they have never committed to a solid sum for sustainable subsidies for healthcare, let alone an overall improvement of the healthcare system. Their chaotic quick-fix subsidies would also never cover what Bulgarians have to pay from their pocket: expensive diagnostic, medication, transplants and prostheses.

The sector of public healthcare is collapsing. Since 1999 the system has been partially privatized. The practice of General Practitioners has become paid (if still 1.5 Euros a visit). Former polyclinics and a number of hospitals have been privatized. Doctors there use the same cabinets and state-sponsored facilities to fund their public and private practice. Places where high-skilled medical service and sciences are developed have remained in the underfunded public facilities. In 2008 the ban on privatization of healthcare facilities was lifted and only specialized hospitals remained protected as public. Staff members at private hospitals, where only a small number of services are covered by state subsidies, reject complex operations and do not accumulate debt, unlike public hospitals where enormous debt has been accumulated[iv]. Under the incentives of costly World Bank reports[v], which denounced Bulgaria as having too many hospitals and too ‘inefficient’ hospital service, it was suggested that the number of beds was also decreased. The cutting of numerous services in the public sector has happened in both top-down and bottom-up manner. The top-down cutting of budgets was paralleled and reinforced by the lowering incentives for doctors and nurses to work in the underpaid public facilities and to serve in depopulated and aging countryside communities. Old specialists and new graduates alike have been pushed into jobs in the private sector. Nurses started leaving and by now more than half of the professionals in this field either work abroad or have found alternative employment. Doctors and nurses either sustain a double employment in public and private practices, or combine their income with ‘non-regulated’ payment on their public jobs. The latter has become a routine not only in the form of corruption and bribery. It also helps avoid the nonsensical division of labor and numerous cases of Catch 22 of unregulated but necessary procedures[vi].

As aggravating as this all might sound, it is news only to the impoverished Bulgarian population, which has until recently had what was seen as a universal right to gratuitous health treatment. This right is still written in the constitution, but is de facto cancelled as a ‘normal’ part of a wider process of ‘development’ characteristic for advanced capitalist societies. On the road to free market society, which Bulgarians were asked to embrace as a conditio sine qua non of ‘catching up’ with the West, every form of human relation is turned into a transaction. In the case of healthcare, patients are turned into clients. Healthcare budgets are transformed into private funds and then into insurance companies, engaged not in medical aid but in ‘risk management’. Doctors and nurses are turned into entrepreneurs competing to sell their service at the highest price. Insurance funds are encouraged to be ‘efficient’ by reducing costs and minimizing the cover of services to those they insure. In the discourses of neoliberal intellectuals and policy-makers who encouraged and carried out this reform in Bulgaria, hospitals are businesses which need to compete on two markets: for funds from insurance companies, and for clients’ preference. If clients cannot pay, too bad: they are not competitive and thus don’t deserve to live. Policy-makers and political spin-doctors support “the entry of the Public Health fund in the market as yet another private fund” (Georgi Anguelov, Open Society) [vii], “the administration of hospitals as a managerial faculty with little reference to medical care” and the incentive that “money should follow the consumer” (Georgi Ganev, Center for Liberal Strategies) [viii]. They are in fact an announcement of a final solution of “free”, “self-regulated” market of human life and welfare. While they are not happy with the only partial privatization of the healthcare system, they try to ‘do their best’ out of the current situation. They opt for minimal state aid for the poor, while everyone else can pick up private security up to the purchase value of their money, and respectively cherry-pick more and better services. This statement is cynical as it stratifies the access not just to services, but to life in dignity and to life in general. The few liberal journalists who work on the question of healthcare – widely unpopular in the Bulgarian media and usually featuring the ‘crime’ or ‘personal drama’ section of tabloids as the story of Dobrinka Krumova – also call for the full entry of the market into the healthcare sector. Decrying the ‘monopoly’ of state-owned Health Fund and the subsidies that governments still pays for healthcare, such voices insist on the total marketization of healthcare[ix].

Against this background, the unbearable lightness with which the majority of Bulgarian administrators, doctors, and nurses, but also the majority of Bulgarians, have given up on the idea of gratuitous public healthcare is both concerning, and symptomatic. It demonstrates how neoliberal incentives of individual self-interest and ‘healthy’ competition – which play on a social-Darwinist trope of the survival of the fittest – have resonated with societies where discourse and practice have been emptied out of any mention or gesture of solidarity, community, and social justice. Further evidence to this transformation is the fact that some of the harshest reforms in the public health sector have been made over the last 300 days while Bulgarians have been out in the streets. Decrying the government’s involvement with shady business networks, the protesters never expressed grievances against its inhuman healthcare reforms which happened in daylight. After allowing that all healthcare funds are turned into insurance companies, the government of the Bulgarian Socialist party – a hard-core neoliberal party representing the interests of big capital – proposed a ‘necessary’ 20% budget cut in the field of public healthcare.[x] Given the current situation in public hospitals, and the dependence of most Bulgarians on the crumbs of redistributed money and healthcare subsidies, such a cut means an effective genocide. Yet, the few liberal  media writing seriously about this subject have retorted with accusations against the state of the ‘failed privatization’ of healthcare, the state ‘monopoly’ and the ‘high state subsidies’ in this field. And while over the last year and a half ten Bulgarians committed violent suicide via self-immolation because of the increase of the electricity price, with the ‘well-intended’ healthcare reform we can now anticipate a next, wider, and more bloody wave of ‘unintended’ mass murder. A murder, which Bulgarian protesters and civil society could prevent if they shifted focus from ‘moral indignation against corrupt and dysfunctional capitalism’ to a moral indignation against capitalism as such. But as this seems too much to hope for in neoliberal Bulgaria, we can just wait for the moment in which the last straw will break the camel’s back – and a healthcare system that kills is just one of the possible candidates to be this straw.