Medical services in invasive cardiology worth just over €1 million in 2025 and €522,000 in the first half of 2026 were carried out under a joint activity agreement between the state-owned Multi-Profile Hospital for Active Treatment “MBAL – Silistra” AD and the private company “SMDL Medex – Silistra” Ltd.
Under the terms of the agreement, MBAL Silistra received 22% of the value of the services paid for by the National Health Insurance Fund, while SMDL Medex – Silistra received 78%.
This is shown by the report from an inspection by the Executive Agency “Medical Supervision”, completed at the beginning of August and obtained by Za Istinata under the Access to Public Information Act.
The inspection was carried out following statements by Health Minister Katya Ivkova to the media that she had referred disadvantageous joint activity agreements to the Prosecutor’s Office, the Economic Police and the Public Financial Inspection Agency. According to the minister, such agreements had been used to siphon money from state hospitals.
As an example, she cited an agreement concerning a cardiology clinic under which the hospital received only 20% of the revenue while a private company received 80%.
Such an agreement has existed since 2021 between the state-owned MBAL – Silistra AD and the private SMDL Medex – Silistra Ltd for activities within the hospital’s invasive cardiology unit.
Minister Ivkova’s statement prompted a reaction from the hospital management, which held a special press conference.
What kind of joint activity is it — and is it really disadvantageous?
The invasive cardiology unit at MBAL – Silistra was opened in 2021. It is based on a public-private partnership between the state-owned regional hospital and the private company SMDL Medex – Silistra.
The company was established and is managed by Assoc. Prof. Spas Spaskov, former director of Pirogov Hospital.
The launch of this type of medical unit in Silistra was presented as a significant achievement because it provided access to emergency, life-saving interventions and examinations for which patients had previously had to be transported to Varna or Ruse.
The hospital provides the equipment, the company the specialists
According to the presentation given to the media when the unit opened in 2021, the hospital already had the necessary equipment and operating rooms, but lacked the specialists required to use them.
Under the partnership, the equipment could finally be used for life-saving procedures, while the specialists were provided by Assoc. Prof. Spaskov’s private company.
They included two doctors qualified in invasive cardiology — Georgi Lichev and Georgi Mazhdrakov — who joined the staff of the cardiology department in Silistra.
Similar structures based on joint activity with Dr Spaskov’s company have also been established elsewhere in Bulgaria, including Kardzhali, Pernik and Blagoevgrad.
According to Dr Spaskov, who attended the presentation in 2021, the idea was to provide emergency, highly specialised medical services in smaller towns rather than concentrating them solely in major centres.
The model also envisaged training local specialists who could eventually take over from the external specialists provided by the private company.
What does the joint activity agreement cover?
Under the joint activity agreement between MBAL – Silistra and SMDL Medex – Silistra, the two parties agreed to jointly provide services under specifically listed clinical pathways which neither party was able to perform independently.
To carry out the joint activity, MBAL – Silistra undertook to provide SMDL Medex – Silistra with high-tech medical equipment and other equipment necessary for the clinical pathways specified in the National Framework Contract for Medical Activities.
The hospital also agreed to provide SMDL with temporary use of premises within the hospital buildings, with SMDL undertaking to carry out any necessary repairs at its own expense.
MBAL – Silistra further undertook to provide all medicines necessary for treating patients under the clinical pathway protocols.
SMDL, for its part, agreed to provide at its own expense all medical devices, consumables and contrast agents required for the examinations.
How is the money paid by the health fund divided?
An addendum to the agreement specifies how the funds received from the National Health Insurance Fund’s regional office in Silistra are distributed between the parties.
MBAL – Silistra receives 22% of the value of the joint activity, while SMDL receives 78%.
What the inspectors found about the activities and the money
Under the agreement between MBAL – Silistra and SMDL Medex – Silistra, payments for activities carried out in 2025 amounted to a total of €1,057,437.02, while payments for 2026 amounted to €522,242.43.
Thus, during the period examined, the total amount received by SMDL Medex – Silistra under its joint activity agreement with MBAL – Silistra was €1,579,679.45.
The reports submitted show that the hospital’s total revenue from the clinical pathways covered by the agreement in 2025 amounted to €1,355,688.49.
Of this, €1,057,437.02 was recorded as an expense incurred by the hospital under its agreement with another healthcare provider, SMDL. The 22% share for MBAL – Silistra amounted to approximately €298,000.
For the period from January 1 to June 30, 2026, the hospital’s revenue from the National Health Insurance Fund under the relevant clinical pathways was €669,541.57.
Of this, €522,242.42 was recorded as expenditure under the agreement with the other healthcare provider.
The hospital’s 22% share for the first half of 2026 therefore amounted to approximately €147,000.
The revenues received by MBAL – Silistra from the National Health Insurance Fund and subsequently paid under the joint activity agreement with SMDL Medex – Silistra represented 8.6% of the hospital’s total NHIF revenue in 2025 and 8.9% in 2026.
Why was the joint activity agreement signed, according to the hospital?
“The shortage of doctors with the necessary qualifications, the need to provide continuous 24-hour services, the complex organisation of the work and the objective difficulties in forming a full multidisciplinary team did not allow the unit to begin operating independently within a short period of time,” MBAL – Silistra Executive Director Dr Vasil Slavov wrote in response to the inspection.
According to him, the hospital considered various options for organising and securing the service. Following an assessment, it concluded that signing a joint activity agreement with a healthcare provider possessing the necessary experience, qualified specialists and established organisation was the most appropriate solution.
However, the inspectors from Medical Supervision reached a different conclusion regarding the future organisation of the service.
They found no violations in the activities covered by the agreement and issued no mandatory recommendations.
But given that MBAL – Silistra possesses the necessary medical equipment and technology for invasive cardiology, as well as a medical specialist capable of carrying out the activity, the inspectors concluded that the service should be provided independently by the hospital in accordance with the licence issued to it in 2021.
Asked to comment on this finding, Executive Director Vasil Slavov said that the hospital still could not provide the services independently.
At present, there is one trained local specialist, he said, but that doctor is still a trainee and does not yet hold the required certification to perform the procedures independently.
According to Slavov, the financial distribution under the joint agreement is not disadvantageous to the hospital either.
The hospital receives 22% as net revenue, he explained, while the private company’s 78% share also covers equipment maintenance and repairs to the invasive cardiology unit.
In addition, the private company covers most of the remuneration of the two doctors working in the unit, while the hospital provides only their basic salaries, equivalent to the pay of doctors employed in Silistra.
The question of whether the joint activity in invasive cardiology is financially beneficial, however, will now be left to the new management of MBAL – Silistra.
As Za Istinata previously reported, following a letter from Health Minister Katya Ivkova, a general meeting of shareholders is due to be held to replace the management of the Silistra hospital and appoint an acting director until a competition for a new permanent management team is held.
