Prof. Dr. Kostadin Angelov: "Only when health is a fixed idea can we rely on the future!"

Prof. Kostadin Angelov was born on June 7, 1977, in Sliven. He graduated from the Medical University of Sofia with Master’s degrees in Medicine and Public Health. In 2015, he completed a Master’s degree in Finance at the University of National and World Economy. In 2014, he defended a doctoral dissertation for the educational and scientific degree of Doctor in the scientific specialty of Surgery on the topic “Optimizing the surgical approach and lymph dissection in patients with gastric cancer.” In 2015, he was elected Associate Professor following a competition, and in 2020, he became a Professor.

The career of Prof. Kostadin Angelov began in the Emergency Department – Shock Room at the Emergency Medical Service in Sofia as a resident physician. In 2006, he joined Alexandrovska University Hospital in Sofia as a surgeon. From 2013 until his election as Minister of Health in 2020, he served as the hospital’s director.

Prof. Kostadin Angelov served as Minister of Health (2020–2021) in the third government of Boyko Borisov. He has been a Member of Parliament in the 45th, 46th, 47th, 48th, 49th, 50th, and 51st National Assemblies. He served as Chairman of the Health Committee in the 49th and 51st National Assemblies.

I. Vision, Leadership, and Sustainability

1. How would you define sustainable healthcare in the Bulgarian context – and is it possible within the existing model?

Prof. Angelov: Healthcare is a conservative system that is difficult to change and requires serious effort to transform. Every change in the political system leaves its mark on the healthcare system as well. This makes it unstable. There is a lack of strategic goals and political consensus regarding the health of every individual. The efforts of all reforms to date have been aimed at ensuring accessibility for every Bulgarian citizen. The problem with our system is that there is no effective mechanism for quality control. And as modern medical equipment and therapies have already entered our country, this raises the question of increasing health insurance contributions. Discussions on this sensitive topic are forthcoming.

2. The health system is often in a state of “firefighting.” What type of leadership is needed to achieve stability and predictability?

Prof. Angelov: The leadership problem can be applied to any system. There is a lack of prepared people – those who are knowledgeable and capable. Most importantly, they must be brave, able to make quick decisions, and take responsibility for them. A quick decision is better than no decision. Any help or solution is valuable only when it is timely. A delayed reaction is unnecessary and always wrong. The stability of our healthcare system and its predictability can only be possible when healthcare becomes a conscious national, strategic, and political priority. Only when health is a fixed idea can we rely on the future. Until then, we will wander, suffer the consequences, and continue to lead Europe in morbidity and mortality.

3. How does your experience help you see the whole picture of the health system – and its real needs?

Prof. Angelov: I started my career in healthcare as an orderly, worked as an emergency medic on an ambulance, in an emergency department, and in a shock room. Throughout this period, I observed and accumulated experience and knowledge. For me, there are no secrets or problems in healthcare. There are only solutions. I know the system like the back of my hand and have developed that valuable intuition, thanks to which I sense problems before they appear and find quick solutions to prevent them. Experience always provides added value and results.

4. Where do you think the gaps are, and why have we failed over the years to build continuity when talking about healthcare? Can political instability be an excuse, and for how long?

Prof. Angelov: Bulgaria lacks a political class, which is dangerous for all social systems, including healthcare. So far, it has been managed out of spite, without a goal or direction. The policy of “firefighting” becomes an unconscious behavioral stereotype for every minister. And when this becomes practice, there is nothing to pass on to the next person. There can be no continuity. Healthcare needs to become a priority, and a political consensus on the nation’s health must be adopted by the National Assembly. After that, it’s just a matter of work. Otherwise, the free fall will continue. There is no successful state in times of political crisis. Politicians govern a state, and when they are absent, a crisis of decisions follows, leading to mistake after mistake. These are not excuses, but established political realities worldwide.

II. Policies, Institutions, and Systemic Deficits

1. How do you assess the progress of health reform since the end of your mandate as Minister? Are there real steps toward sustainability, or are we observing cyclicity and stagnation?

Prof. Angelov: Health reform in Bulgaria is either stalling or has already died from so many experiments and mistakes. Every minister comes, leaves their mark, and goes. During my mandate, the electronization of the healthcare system began with the introduction of the electronic prescription and electronic referral, which was the start of the National Health Information System (NHIS). It was very difficult, almost impossible. But the decision could not be delayed. I still remember the date – December 19, 2020. Then, as now, every beginning is difficult. Today we are on the verge of completing the NHIS. It contains all health information. It is sufficient for making quick and correct decisions. It allows for effective cost control. In reality, the construction of this system and its full completion were delayed because of ministers who did not possess the necessary qualities for it.

2. You head the Health Committee – what are the priority tasks you have set for yourself?

Prof. Angelov: To make healthcare a conscious national priority. To change demographic indicators – morbidity and mortality, as well as birth rates. I have said many times that Bulgarians should be healthy, not just cured. Targeted investments in prevention and screening are needed, rather than just treatment. In this sense, healthcare should not have a party color, and in the Health Committee, we constantly strive for this and prove it. Together with all colleagues from all parliamentary groups, we achieve the necessary consensus because we put health first and politics second.

3. What are the weak links that hinder sustainability in the health system – and which reforms are already overdue?

Prof. Angelov: The weak links are many, but the main ones are the lack of financial predictability in the system, the shortage of nurses, and the lack of understanding among individuals regarding a healthy lifestyle. The lack of health education is also a major problem if we want to improve our health and live longer. Many more prevention and screening programs are missing that would provide added value to health. This requires a lot of professional and round-the-clock work. If we don’t help ourselves, no one will.

4. Prof. Angelov, according to many experts, hospital care in our country is bloated – do we really need so many hospitals, and are we treating patients correctly, or are we maintaining a system that is rather economically inefficient?

Prof. Angelov: There are many hospitals, and this leads to an economically inefficient system. This must soon be reviewed, reconsidered, and changed. There are buildings called hospitals that are dangerous for people. The lack of political consensus and strategy is particularly felt here. We all see the problem, but the fear of resolving it dominates over successful treatment. This is also a condition for achieving poor clinical results and poor demographic indicators.

5. Emergency medical services still face difficulties with coverage in remote and sparsely populated areas – what are the real solutions for ensuring a fast and quality response everywhere in the country?

Prof. Angelov: We are a phenomenon in the world, but in fact, we always have been. Perhaps that’s where the saying “Good work, but Bulgarian style” comes from. We started building air medical services with helicopters without having finished the reform, equipment, and staffing for ground emergency services. It’s like putting on a tie without having a shirt. Ground emergency services need financial resources; they need quality ambulances – not just ambulances, but quality ones that don’t spend much time in repair shops. Emergency services need to update the equipment they work with. Employees need dignified pay for their work, for their night and overtime shifts; they need uniforms, and they need them regularly. It sounds basic and mundane, but these are the realities.

6. The system of general practitioners is the backbone of outpatient care, but it is often criticized for formal service and overwork – what changes are needed for the GP to be the patient’s true first contact with the health system?

Prof. Angelov: For the most part, patients do not respect the Bulgarian doctor. This must change, and we must restore our respect and trust in doctors. Our trust in the system. General practitioners are a good solution. In recent years, we have directed serious financial resources into the outpatient medical care system. This was also an acknowledgment of our colleagues’ work. However, problems have also caught up with GPs. Few people want to specialize in General Medicine and become general practitioners. The average age of currently working GPs is high, and this is already a problem that requires solutions. Political vision is needed.

7. Nurses and midwives are calling for the right to contract directly with the NHIF without the mediation of a doctor or hospital – is such a reform possible in the current system, and what risks or benefits do you think it holds?

Prof. Angelov: At the beginning of the interview, I told you that our healthcare system is conservative and finds it difficult to accept any innovation or change. It is the same here. I was the first minister who insisted on including 20 million in the NHIF budget for nursing practices, and this became a reality in 2021. This reform is possible and, like any other, is subject to public discussion and negotiation.

8. The National Framework Agreement is at the core of the system. Do you think it should be reconsidered toward more sustainable and flexible financing?

Prof. Angelov: The sustainability and flexibility of financing are decided in the NHIF Budget Act, not in the National Framework Agreement (NFA). I believe the NFA should include effective mechanisms for quality control of the medical/health activities provided and clear rules. There is also a need to strive for a reduction in bureaucracy.

9. Digitalization is cited as a driver of sustainability. Where does Bulgaria lag behind the most – and where is there a real chance for a leap?

Prof. Angelov: I can only speak for healthcare. I believe healthcare can be given as an example of a digital leap. All your health information is now just a click away. It is on every smartphone, provided you have downloaded the necessary application.

10. How do you assess the effectiveness of cooperation between institutions – MoH, NHIF, BMA, and patient organizations? What is missing for them to work in sync?

Prof. Angelov: Such cooperation exists; it is also formalized. The NFA is an expression of this. It bears the signatures of the NHIF, MoH, BMA, BDA, and BPU. Patient organizations are on the Supervisory Board of the NHIF – where decisions are made. Otherwise, beyond this formality, informal conversations have always yielded greater results and value. They depend on subjective factors. As strange as it may sound, the healthcare system has its own mechanisms to recognize when a person from high state bodies fits into the system or not. If they do not fit into the system, it does not accept them and rejects them, and then that person cannot achieve anything, absolutely nothing. They are wasted time for healthcare and for the people. The immune system of healthcare has a memory for many such newcomers who are remembered for nothing.

11. Sustainability requires long-term solutions, often beyond the horizon of a single mandate. Is there room for strategic planning in a politically unstable environment?

Prof. Angelov: Strategic planning requires a stable political environment and management system. Currently, Bulgaria is divided into two feuding parts. Unfortunately, people do not realize they are being used so they can be more easily governed. If unity is important for us to pursue goals and defend values, there are state bodies that divide the people. This is precisely a sign of the lack of a mature political class in general.

12. What is your vision for longevity as a systemic priority? Is the system ready to meet the needs of an aging population?

Prof. Angelov: This is a global trend, and the more medicine advances, the more pronounced it will become. Longevity is a way of thinking, an awareness, and a priority for the individual, in the family, in politics, and in the state. Either it’s there, or it’s not. We are very far from this way of thinking. Daily targeted measures are needed in this direction – health education, large investments in health – prevention and screening from conception to death. This is a conscious way of life. I hope we will soon step firmly on this path. If we start now, we will reap the first fruits in twenty years.

III. Projects, Vision, and Personal Perspective

1. Tell us about the projects you are currently working on. How do they fit into your idea for a long-term transformation of the sector?

Prof. Angelov: I repeat, every change in the sector is difficult; it requires a lot of effort, decisions, and leadership. To ensure support, days of conversation and persuasion are needed. The most important thing for me is to succeed in convincing everyone of the need for health education. Only healthy people can live long lives and have a predictable future. I am working on this. We also adopted a decision of the National Assembly in this direction. I hope the Ministry of Education and Science will make the necessary efforts to make the National Assembly’s decision a reality.

2. If you could introduce one key measure again today, without political barriers – what would it be?

Prof. Angelov: I would optimize the number of hospitals and create strategic hospitals in every region that would guarantee access and quality healthcare for everyone. I am against having a hospital that offers only “access” without guaranteeing quality.

3. What motivates you to stay connected to healthcare – even outside the position of Minister?

Prof. Angelov: I am inextricably linked to healthcare. This is what I wanted, what I studied for, and what I do. If we look for motivation formally, we might find it difficult. Motivation is a result of character. And in my case, there is plenty of it. I am the Chairman of the Health Committee. This position is strategic for our sector. In the healthcare system, I have been everything – from an orderly to a minister. Nothing can surprise me.

4. Where do you see yourself – and Bulgarian healthcare – in 5 years? What would you like to leave behind as a legacy in the system?

Prof. Angelov: I don’t make plans for positions. I only plan the results of my work. I want the system to provide added value to the life of every individual. Prevention, screening, health education.

5. Prof. Angelov, you have held leadership positions for years that require resilience and a strong character. What from your childhood and upbringing played the biggest role in building this character?

Prof. Angelov: The upbringing my mother gave me. She shaped my character. I never give up; I am never satisfied with less than what is required. Everything must be executed perfectly, down to the smallest detail. I must have an A in everything and never less. This overachiever syndrome has not left me to this day. I don’t know what rest is or how people rest, but my brain works round the clock. I was raised in emotional neutrality. This is a very important condition for quick decisions.

6. How does parenthood and raising a child change your understanding of how people are led and how character is built?

Prof. Angelov: A difficult question. Iliyana and I are of one mind on this topic. We raise and educate our son Samuil ourselves. We try to play, to teach him order, rules, and tolerance. We live in support and love. And he teaches us patience. The symbiosis is absorbing, recharging, and sufficient. As for leading people, it’s an intuition. Either you can do it, or you can’t. It isn’t taught; it isn’t learned. You are born with it. Intuition. A community either accepts you or rejects you. It’s simple.

7. Prof. Angelov, you are an established professional in medicine and politics – in your opinion, is true and sustainable success possible without a stable family support? How has your personal world supported you along the way?

Prof. Angelov: Family is the most important thing. Without it, there is no meaning. Life logic is missing. Nothing is worth the effort. Iliyana is a wonderful person. She loves me and shows it to me round the clock. With me, it’s not exactly like that. But in my most difficult moments, when the light went out, she was right there by my side, believed in me, and gave me strength. And that is wonderful. We strive to teach our son the same.