Stanimir Hasurdjiev explains the key role of the National Patients' Organization (NPO) in Bulgaria and discusses the main areas that he is working on to ensure that patients are heard and can benefit from the best treatments and care available at a reasonable price.
You are working in different organizations besides the National Patients’ Organization. Can you explain how these roles help serve the patients in Bulgaria?
All my roles are somehow linked. First, I chair the National Patients’ Organization (NPO) in Bulgaria, the biggest umbrella association with more than 80 other patients’ member associations, which expresses the views of all patients in the country. We are also the most developed patient association in the region as we are included in all the decision-making and policy making processes so we can amend the system in a way that serves the citizen. Additionally, I am happy to confirm that our country also has a piece of legislation in healthcare that establishes the nationally representative patients’ organization, a crucial organization that allows patients to be involved in different institutions, discussions and committees. As a good example of that, we have one patient representative sitting at the board of the National Health Insurance Fund (NHIF) amongst employers, government and labour unions while we have other working on the Health Technology Assessment (HTA) process to involve patients as well as avoid potential conflicts of interest.
Moreover, two years ago, the NPO helped in the establishment of a permanent consultative body for the council of Ministers called the “Health partnership”. It helps us to establish a certain stability in healthcare policies despite the political instability that can happen in the parliament.
At an international level, the NPO is also a member of the European Patients’ Forum where I am a board member for the third term. The forum works directly with European institutions. One of our latest initiatives is to create a pan-European multi-stakeholder healthcare platform focused on solving issues and improving the access to healthcare in Europe. It is called the “Patient Access Partnership” where I am the secretary general and it gathers all the key stakeholders on the European level. Whatever we do in Bulgaria or in Brussels should be reflected and have a positive impact on people’s lives in Europe and especially in my country.
What is your assessment of the healthcare environment in Bulgaria from the patients’ point-of-view?
We are far from a patient-oriented healthcare system but the fact that patients are included in the discussions is already a great move. The major issue I see right now is the amount of public expenditure in the country. The system has to work with 50 percent of what it needs and this is the major source of the problem as the rest ends up being paid by patients. Furthermore, with low financial resources, many healthcare professionals are misusing the system, giving false diagnostics and hyper hospitalization.
In terms of market access for medicines Bulgaria stands well but, when looking at the numbers for patients’ use or the administrative barriers, we can see that having medicines accessible to patients does not mean that they are affordable, appropriate, used properly or available in time. Indeed, the registration and reimbursement process in Bulgaria is still quite long as it can take up to three years after the EMA registration and, even when this registration is done, there are still a lot of administrative barriers to overcome before getting to the patients. Over recent years, Bulgaria overregulated the access to innovative medicines which led many companies to wait a few years before registering their new products mainly because of the administrative pressure, uncertainty and the lower price in Bulgaria.
What are the main issues Bulgaria should overcome to ensure a better access to medicines for patients in the country?
Firstly, many consider that the HTA introduced is another barrier to the introduction of new products. Indeed, the HTA works with data and a real methodology and this is difficult to implement in a country like Bulgaria where there is a lack of capacity, data and infrastructures to work effectively. In my opinion, it would be more relevant to create a regional HTA rather than a national one. In this regard, with the CEE for Health organization, we are piloting a project to create a methodology for a joint HTA gathering five countries.
Pricing is the other great challenge. The reference pricing is an interesting system as every country has more or less the same price for a product but the prices are set according to the richer countries creating inequalities with the smaller markets like Bulgaria. Moreover, the free movement of goods that some use to buy drugs in Bulgaria and sell them in more expensive markets as well as the parallel trade has had direct consequences on the access to medicines. It creates shortages, especially in life-saving medicines areas, and the government alone is not able to deal with that. Therefore, at a European level, we should establish a fairer pricing model with a differentiation between the richest and the poorest countries.
In that case, what would be your suggestion to establish a fairer pricing model and reduce parallel trade?
I do not believe using the same system with the average price instead of the lowest one would solve the problem. It worked well when all countries had the same economic level but now, with the new member states like Romania, Bulgaria or Croatia, the price did not go down. Therefore, my recommendation would be to create a reference pricing for each cluster of countries with similar economic developments such as the size of the market, the GDP or drug affordability.
As for parallel trade, it needs a European solution. Many European politicians agree that medicines are different from normal goods because they are actually saving lives. I agree and believe there should be a different legislation for medicines. For example, they should be specially regulated and not included in the free movement of goods within Europe in the same way we regulated the tobacco industry. Then, it will be possible for smaller countries to get more affordable medicines.
Many key opinion leaders have highlighted the strong collaboration between each stakeholder in the Bulgarian healthcare ecosystem. How is this phenomenon visible in the National Patients’ Organization?
In all the programs we have launched to support patients, raise awareness or educate healthcare professionals, we have received strong support from the industry. Unfortunately, our government is hardly supporting these actions as they have other priorities so companies play a key role for both doctors and patients.
However, we are much more careful here and to protect ourselves from bad practices, or bad publicity, we have clear principles that are strictly followed. One of them is about transparency, especially in the funding and the activity; in addition, we enforce multi-sponsorship that allows companies to come together. On top of that, we also meet with industry associations several times a year to share each other’s expertise and discuss upcoming projects. Both in Bulgaria and in Brussels, each stakeholder has found its place and can bring its knowledge and ideas to the discussion.
What is your vision for the Bulgarian Healthcare system and the role the National Patients’ Organization will play in the upcoming years?
The current and future major challenge of the system is the underfunding so I am happy to see the current government is putting the reshape of the health insurance model as a key priority. We know that there is not enough political intentions to raise the amount of fund dedicated to the NHIF but the conversation will go towards how to build on what we already have in terms of insurance. I think that our efforts should be on collecting more money through public funds and reduce the direct co-payment which will help deal with all the malpractices.
The hospital map should also be reviewed as a second priority. In Bulgaria, we have more than 300 hospitals and around 60 of them being located in Sofia. It is interesting that hospitals are growing every year while the population is unfortunately decreasing. This situation is creating a strong competition that goes against the system so we would need to re-organize the hospital map, even if it is a difficult decision to take. Bulgaria should look at already existing effective models from Europe or the USA to improve its system, obtain better results and make it friendlier to the patients. As a possible solution, closing a hospital might not be the best decision but reorganizing its services to fit the needs of the population might be a better way.
Concretely, the role of the NPO is to provide as many models as possible to the decision and policy makers so we can find the best system for patients and all the Bulgarian stakeholders.
