Dr Strahil Efremov is an orthopaedic surgeon in a private hospital in Bulgaria

"I received my medical education in Bulgaria, and later specialized in hand surgery in France, with some regular exchanges with clinics in Poland and the Czech Republic. I have worked in various health institutions in Bulgaria and have had different roles in different health system settings. When comparing the Bulgarian health system to those in other countries in central and eastern Europe, I feel we are still in the middle of the transition process. We have successfully completed primary care reform and now we are moving forward with restructuring specialized care and services.  

In 2002, I moved to a private practice, partly for financial reasons, but for other reasons as well: the desire to be in a setting where conditions and rules were clear and strict and to be able to decide for myself what is best for my patients. In the public hospitals, it is difficult for medical professionals to be confronted every day with patients who know their rights and demand and expect, rightly, the best and latest technological advances to be used to ease their condition, while the money available through the compulsory state insurance schemes is often insufficient for this. In many ‘transition countries’ the doctor is left at the front, having to be the one to tell the patient that, yes, the state has included this treatment in the benefit package, but in fact, no, this does not cover the costs. You enter a grey zone where the patient needs to pay extra, so therapeutic decisions are made based on considerations that are not only medical. Here in private practice, people are in principle able to pay, so I do operations every day the way I know is best. Additionally, I often undertake operations in some other, non-private hospitals, in cases when my intervention is requested.  

I truly hope that by 2010 there will be a full review of health insurance schemes, and modern mechanisms for health financing will be introduced. A real concern for most Bulgarian health professionals is a true evaluation of the real costs of medical products and services. I am very optimistic that, once costing calculations are made and rules are put in place to oblige health specialists to deliver consistently high-level services, things will significantly improve.  

It is a responsibility of society as a whole to guarantee that those who are most vulnerable – the elderly and children – have access to good-quality services. We cannot abandon them. In this respect, the health system is like an economic regulator, which should address and adjust the disparities in the economic status of different population groups. This should and will come with making the health insurance market more competitive, especially for actors at the European Union level. With its highly qualified health workforce, I believe Bulgaria has a good prospect of completing its health reforms in a few years. And in this process, we must never, ever forget the importance of disease prevention."