This chapter provides an overview of access and quality of care in Bulgaria’s healthcare system, assessing its performance, recent policy reforms and opportunities aimed at improving equity, efficiency, and resilience. The first section analyses unmet healthcare needs and services utilisation, highlighting the suboptimal use of primary healthcare and persistent geographical disparities in access. The second section explores the quality of care, outlining key challenges and policy initiatives to reduce avoidable hospitalisation and improve cancer care. The third section focusses on mental health needs and service provision, identifying gaps and policy efforts to strengthen community-based care. The last section examines long-term and palliative care, underscoring limited resources and capacity constraints.
OECD Reviews of Health Systems: Bulgaria 2026
Abstract
Bulgaria has reduced unmet needs for medical care over the past decades, yet the gap between high and low incomes is large
In 2024, 1.1% of people reported an unmet medical need due to cost, distance, or waiting time, below the OECD average of 3.4% (Figure 3.1). While 0.3% of households in the highest income quintile reported unmet needs, this figure rises to 2.7% for households in the lowest income quintile. Over the past decades, Bulgaria significantly reduced its levels of unmet needs for medical care from 15.3%, to 1.1% in 2024 (Eurostat, 2025[1]). Unmet dental care needs also fell from 16.5% in 2008 to 1.8% in 2024 (Eurostat, 2025[2]). The main drivers of unmet medical needs are cost and travel distance, due to direct payments and the unequal distribution of healthcare provision.
1. 2023 data. 2. 2020 data. 3. 2018 data.
Source: Eurostat, based on EU-SILC and the 2023 Canadian Income Survey.
Routine care remains costly due to relatively low population coverage
In Bulgaria, the share of uninsured people is estimated at 6% in 2023, however, according to the national data sources, the percentage of uninsured people rises to 11% and 12% (Republic of Bulgaria, National Health Insurance Fund, 2022; Republic of Bulgaria, Ministry of Finance, 2021). It is estimated that about 1 million people did not have health insurance, out of which roughly 150 000 were Roma. It is estimated that one in four Roma people were not covered (ERGO Network, 2022[3]), as many Roma are unemployed or work in the grey economy and do not apply for benefits because of conditionality and eligibility (lack of ID card or proof of residence). Even the Roma who have insurance are often unable to access medical services in their vicinity because these are missing in remote areas and Roma settlements. In addition, a high proportion of people have interrupted health insurance rights due to irregularly paid health contributions (for example, around 21% in the Pleven region) (Kostadinov et al., 2023[4]). The National Health Strategy for 2021‑2030, the National Strategy for Reducing Poverty and Promoting Social Inclusion 2030, the National Strategy for People with Disabilities 2021‑2030, and the National Strategy for Roma Integration 2020 aim to address coverage gaps by improving the acceptability of care and increasing the number of preventive check-ups amongst vulnerable populations.
The Health Mediator “zdraven mediator” model aims to improve access to healthcare services for vulnerable population groups, notably the Roma population and other minority groups. The health mediators are women and men of different ages, coming from communities in which they work and speak the community language (Romani, Turkish and Wallachian). The main tasks of health mediators are to communicate with local health and social institutions, to assist and accompany people to these institutions when needed, to assist general practitioners in obtaining better vaccination coverage, to help people fill in documents and to organise health information meetings in the community, to contribute to increasing the health culture of local vulnerable groups through explanation and consultation, to implement programmes for sexual and reproductive health, and to assist the organisation of prophylactic check-ups with mobile units. The Bulgarian health mediator model was developed based on the experience of the Dutch Institute of Public Health and other European countries. The National Network of Health Mediators (http://www.zdravenmediator.net/en/index.php), established in 2009, develops and implements the Health Mediator model at a national level. In 2025, the state provides a delegated budget for the work of 352 health mediators, distributed in 157 municipalities of the country in the 28 regions of the country.
Each year, a list of municipalities that should receive state financing is prepared by the National Network of Health Mediators, which is then sent to the Ministries of Finance and Health. All health mediators in Bulgaria are selected through competitive examination, which is advertised by the municipality. Secondary education is the minimum requirement to become a health mediator. The potential candidates are interviewed by a commission whose members are representatives of the municipality, the RHIs, National Network of Health Mediators, general practitioners, and members of the local vulnerable community. The health mediators follow a professional training in the Medical University in Sofia and should successfully pass a final exam. The programme faculty includes lecturers from the University and experts from the National Network of Health Mediators. Once successfully passed, health mediators receive certificates for professional qualification allowing them to be employed by the municipalities.
Access to pharmaceuticals is challenged by high out-of-pocket costs and potential shortages
Drug policy is part of the national health policy under the responsibility of the Ministry of Health. Other key bodies involved in drug policies are the Medicines Executive Agency (Bulgarian Drug Agency) and the National Council on Prices and Reimbursement of Medicinal Products (which carries the responsibility for HTA as of 2019) and the NHIF (which carries the responsibility for HTA for medical devices). The NHIF’s Supervisory Board issues a list of the conditions for which the NHIF covers medicines, as well as medical and nutritional products, based on a Ministry of Health ordinance. The NHIF budget includes a cap for outpatient medicines, while providing 100% coverage for some specialty medicines such as oncological diseases.
In 2022, 33% of current health expenditure was on medical goods, prescribed and over-the‑counter, which was higher than all OECD countries, where the average is 17.2% (see Chapter 4). OOP spending accounted for more than one‑third of health spending (35.1%) in 2022, of which, pharmaceuticals comprised more than two‑thirds in 2022 (69.3%), which negatively effects access. The regulatory process of market entry and posterior reimbursement of new medicines is governed by the 2007 Medicinal Products in Human Medicine Act. To be reimbursed, medicines must have first been included in the Positive Medicines List which includes, as per Art. 262, medicinal products dispensed on prescription, necessary to cover the healthcare needs of the population, and to be covered by NHIF, state budget, and healthcare establishments. Following approval of non-generic medicines, a centralised process of negotiation of discounts takes place between the NHIF and pharmaceutical companies, including rebates and conditions for refunding. The NHIF also conducts annual mandatory negotiations on discounts with market holders for medicines that are part of national, regional, and municipal health programmes. Some measures are being adopted to improve the mechanisms determining co-payments on medicinal products so as to create a balance between innovation funds, the interests of the industry, fair pricing, and improving access to quality medications. The NHIS will likely increase monitoring on pharmaceuticals and support data‑informed decision making.
Most pharmacies are owned by independent businesses, although hospitals and other healthcare establishments may operate pharmacies for their own needs. Prescription medicines are sold exclusively in pharmacies, while over-the‑counter products are available at both pharmacies and drugstores. The number of pharmacies has been decreasing over the last decade. In 2015, there were 4 200 establishments, dropping to 3 200 in 2024; around 2 360 were under contract with NHIF. There are also over 900 drugstores and 130 online pharmacies (neither category is allowed to sell prescription drugs) in 2024. To improve access to pharmaceutical care, the National Pharmacy Map is intended for territorial distribution and regulation of access to medicinal products, medical devices, dietary foods, and pharmaceutical care, aiming to improve access based on population needs.
Bulgaria is also seeking to address shortages of essential medicines, an issue which is shared with many countries around the world. These shortages have persisted since the COVID-19 pandemic and are heightened during the winter months. Tackling the shortage of diabetes drugs and rare medicines has been a major concern for the Bulgarian authorities in the last few years. Bulgaria is doing so by implementing the Specialised Electronic Tracking and Analysis System of medicinal products (SETAS) administered by the Bulgarian Drug Agency which aims to monitor the availability of medicines included in the Positive Medicinal List and paid for with public funds (Republic of Bulgaria, 2020[5]). For example, it will require entities across the distribution chain to submit information to SETAS.
Access to healthcare faces significant challenges arising from regional disparities and shortages of general practitioners and nurses
The shortage of healthcare workforce, notably general practitioners and nurses, undermines access to outpatient care in rural and remote areas, also threatening future healthcare system sustainability (see Chapter 4). The distribution of general practitioners varies, with a more than two‑fold difference between the lowest, Kardzhali (0.31 per 1 000 population) and the highest, Pleven (0.83 per 1 000 population) (Figure 3.2). This presents a national average of 0.59 per 1 000 population, below the OECD average (0.84 per 1 000). The National Map of Long-Term Health Needs aims to guide future investments towards more equitable and sustainable regional development and increased access to healthcare in the long term. This aligns with Bulgaria’s National Health Strategy for 2021‑2030 and reflects the reforms envisaged in the NRRP. Incentives are also planned through a dedicated line item in the NHIF budget for the opening of pharmacies in isolated mountainous regions and amending the law to allow providers to open their own outpatient centres where there are service deficits. The Ministry of Health and several districts also initiated “Doctors in Small and Remote Settlements”, a pilot in which specialists from district hospitals provide services to underserved local communities. This initiative is expected to be expanded through the NRRP via outpatient facilities staffed by medical specialists and healthcare professionals in small communities.
Source: National Health Information System, 2025.
Emergency care is not easily accessible in rural and remote areas, especially for urgent care of complex conditions like stroke
Emergency care in Bulgaria is provided by a network of facilities, which include, the emergency departments of 34 public hospitals, 27 Emergency Medical Care Centres and the 200 branches and 6 outsourced teams opened to these centres, and in hospitals without emergency departments a service offer for emergency admission of patients are provided. Medical triage in the emergency medical care system is carried out upon receival of call by mobile emergency medical teams at the place of the incident and upon admission to the emergency department. In areas where general practice services do not exist, emergency care also provides outpatient care services.
Emergency care in Bulgaria is challenged with inequalities in access to emergency care and poor infrastructures. Approximately 1 000 000 people live in hard-to-reach and remote areas with difficult access to hospital emergency care services. About 15% of settlements have an access time for hospital emergency medical services exceeding 30 minutes. Access by motor vehicles is severely limited in some areas due to undeveloped or compromised road networks, difficult terrain, and complex weather conditions. According to the national statistics, the current location of emergency medical care structures provides access of a mobile medical team with an ambulance to the population of the country within a time frame of up to 8 minutes for 87% of people in settlements with a population of over 25 000 people, 73% of people in settlements with a population of 10 000 to 25 000 people, 61% of people in settlements with a population of 4 000 to 10 000 people and 51% of people in settlements with a population of less than 4 000 people. Around 30% of Bulgaria’s territory is mountainous, which, combined with severe winter conditions, creates problems for timely access to emergency care. Bulgaria also lags in providing complex urgent care for stroke patients. Specialised stroke units and the availability of modern interventional treatment are available in a few medical facilities, limiting equal access across the country.
The 2030 National Health Strategy aims to develop capacities for emergency assistance and emergency response. Some of the planned measures include implementing a stroke recognition protocol (FAST), training dispatchers, and emergency teams, planning ambulance routes in major cities to minimise travel time, introducing mandatory advance telephone contact with receiving hospitals, fast reception, and introducing telemedicine for remote areas. Under the Operational Programme “Regions in Growth” 2014-2020, financed through the European Regional Development Fund, “Support for the development of the emergency medical care system” project aims to renovate and modernise the building stock and equipment in the emergency care system throughout the country. The NRRP also covers the emergency care system by air (HEMS), with helicopters covering the territory of the whole country. While developing infrastructures, Bulgaria should ensure there is an available and trained health workforce for emergency care services. Bulgaria should also intensify its efforts to strengthen primary care services with adequate health workforce to avoid bottlenecks in the healthcare system and increase awareness of the population on the use of emergency care services.
Although Bulgaria has data infrastructures through the NHIS, it does not have a quality management system based on a framework, and reliable indicators and monitoring mechanisms for healthcare system performance. Analysis of healthcare quality relies on process indicators such as vaccination rates, screening activities, and hospital admissions. The assessment of quality of care and patient safety is hindered by lack of regular measurements on key indicators such as avoidable hospital admissions, prescribing of medicines, and patient-safety events. Measuring quality of care from people’s perspectives, through PROMs and PREMs, is also not developed in Bulgaria. Future efforts should focus on developing quality management systems through the establishment of a monitoring and reporting framework. Such framework can facilitate a better understanding of health systems and guide developing a broader vision for health system performance assessment, including healthcare quality by drawing on clear, robust and measurable indicators as highlighted in the renewed OECD Health System Performance Assessment Framework (OECD, 2024[6]). Participating in the OECD’s Patient-Reported Indicator Surveys initiative can also support Bulgaria to develop robust systems to assess quality of care by systematically measuring patient-reported health outcomes and care experiences of people with chronic conditions (OECD, 2025[7]).
While cancer mortality is around the OECD average, 5‑year survival rates are low, calling for intensifying efforts on screening, diagnosis and treatment activities
Cancer is the second leading cause of death. The most common causes of cancer were lung, colorectal, breast, pancreas and prostate cancers (OECD, 2023[8]). Cancer mortality was 190 deaths per 100 000 population in 2023, lower than the OECD average of 191 deaths and the neighbouring EU5 of 239 per 100 000 (Figure 3.3). The cancer mortality rate is higher for men than women, similar to other OECD countries but the gap between men and women is higher than the OECD average (112 and 91 per 100 000 population, respectively), though below the neighbouring EU5 average (133 deaths).
Note: The data refers to 2023 data. 1. 2021-2022 data.
Source: OECD Health Statistics 2025, based on the WHO Mortality Database.
Between 2010 and 2014, five‑year survival rates for breast, cervical, colon, and lung cancer were all below the OECD and neighbouring EU5 averages, most notably in the case of lung cancer (7.7% versus 17.1% for OECD) and cervical cancer (54.8% versus 65.5% for OECD) (Figure 3.4). Despite this, Bulgaria has experienced positive increases in survival between 2004 and 2014, most notably for colon cancer (from 43.9% to 52.4%) and breast cancer (70.9% to 78.3%). More recent data is needed to determine whether this progress has been sustained, allowing Bulgaria to potentially close this gap.
Note: Data correspond to the 2010-2014 period. EU4 countries represent Czechia, Poland, the Slovak Republic and Slovenia.
Source: OECD Health Statistics 2025.
Within the framework of the National Program for the Prevention of Chronic Non-Communicable Diseases 2021-2025, screening examinations for oncological, pulmonary and heart diseases and type 2 diabetes are planned. Due to insufficient financial resources, a small part of the activities planned under the Program were being implemented. Nevertheless, Limited national resources and low levels of health literacy hinder effectiveness of preventive activities.
Participation in cancer screening and vaccination activities is low
Participation in breast and colorectal cancer screening activities is low. In 2019, 36% of women aged 50‑69 years reported having a mammogram for breast cancer screening in the past two years, below the OECD average of 57% and EU5 average of 46%. The percentage of people aged 50 to 74 years reported having a faecal occult blood test for colorectal cancer screening in the past two years was 4% in 2019, below the OECD average of 45% and EU5 average of 33%. In 2022, despite free human papillomavirus (HPV) vaccines for girls aged 10‑13, 9% of all girls aged 15 were vaccinated against HPV. In 2019, 57% of women aged 20‑69 in Bulgaria reported undergoing cervical cancer screening in the last three years, approaching the OECD average of 58% and higher than the EU5 average of 52% (Figure 3.5).
Within the framework of the programme of the National Program for the Prevention of Chronic Non-Communicable Diseases (2021-2025), screenings were conducted free of charge for breast, cervical, colorectal and prostate cancer. Between 2021 and 2024, breast cancer screening was conducted among women aged 30 to 69 in 10 regions. Colorectal cancer screening was conducted among men aged 18 years and older in eight regions. Cervical cancer screening was conducted among women in all 28 regions. In 2024, the budget of the National Program for the Prevention of Chronic Non-Communicable Diseases 2021-2025 was increased to conduct screening for cervical cancer, to be organised by the NHIF, the Ministry of Health and the RHIs. The screening programme targets all women aged 20 to 29 and 40 to 49 (regardless of their health insurance status) and women aged 30 to 39 for those without any insurance. In 2024, prostate cancer screening was conducted among men aged 18 years and older in six regions. Since 2023, Bulgaria launched from the Ministry of Health with the support of different professional organisations and other associations to increase awareness about HPV vaccinations. Since the beginning of 2024, an increase in the number of vaccinated people has been reported, with the number of girls covered with the first dose of the HPV vaccine during the year being twice as high compared to 2023. In addition, in April 2025, the Council of Ministers also adopted a National Program for Primary Prevention of Cancers Caused by Human Papilloma Virus (HPV) 2025-2030 (Ministry of Health, 2025[9]). The Program provides free vaccination (vaccine and its administration) for girls aged 10‑14 and boys aged 10‑13/14. A gradual increase in the age group for girls is planned until reaching 21‑year‑old women in 2029.
Note: Data refer to 2023 unless otherwise stated. Programme data unless otherwise stated. Bulgaria data refer to 2019. Data for the United Kingdom refer to England. 1. Survey data. 2. Latest data from 2020‑2022.
Source: OECD Health Statistics 2025, the Portuguese National Programme for Data in Oncology (2024).
There are significant differences in screening rates by socio-economic status, as Bulgarian women in the highest income quintile reported higher cervical cancer screening rates (71%) than those in the lowest quintile (31%) (Eurostat, 2022[10]). Screening rates for breast cancer among women aged 50‑69 in the last three years reveal similar differences: 66% in the highest quintile compared to 31% for the lowest quintile (Eurostat, 2022[11]). These are the largest income‑based gaps observed when compared to OECD countries. For colorectal cancer, the gap is similar to the OECD average, though overall it is quite low at 3%. There are also disparities by location, as most screening activities occur in urban centres, leaving those in rural areas with limited access to these important services (OECD, 2023[8]).
Despite the existence of cancer risk factor prevention policies and various health promotion initiatives, the overall impact has been limited (OECD, 2023[8]). The National Cancer Plan, adopted in 2023, targets early detection with screening programmes for colorectal, breast, cervical and prostate cancers through to 2027 (OECD/European Commission, 2025[12]). However, it does not mention population-based screening. The main obstacles to meeting the targets of the prevention programmes include the limited involvement of representatives from all stakeholders (national and regional health policymakers, the health insurance fund, the cancer registry, medical professionals, patient organisations, teachers, and community mediators); the lack of a comprehensive cancer health strategy – especially among vulnerable populations (such as migrants, people with low education levels or low socio-economic status and people with disabilities); and limited funding (in 2020, health prevention represented only 2.8% of total health spending in Bulgaria compared to 3.4% on average in the EU) (see Chapter 4). In 2025, two screening programmes are in the process of being approved, an implementation of the National Plan for Combating Cancer in the Republic of Bulgaria 2027: “Cervical Cancer Screening Program 2025 – 2030” and “Colorectal Cancer Screening Program 2025 – 2030”. The financing of the upcoming screening programmes will be carried out through the approval of additional expenses and transfers from the budget of the Ministry of Health.
Bulgaria should develop its medical equipment for cancer diagnosis and care
Bulgaria’s ability to address low cancer survival rates is partly determined by its diagnostic and treatment capabilities. In the case of positron emission tomography (PET) scanners, Bulgaria has 1.7 units per 1 000 000 population, slightly higher than the neighbouring EU5 average of 1.6 units, but below the OECD average of 2.6 units (Figure 3.6). On the other hand, there is a significant number of radiotherapy units in the country, 11.5 per 1 000 000 population, which is above the OECD (8) and neighbouring EU5 averages (8.1).
With these challenges ahead, in 2023 Bulgaria adopted the National Plan to Fight Cancer in the Republic of Bulgaria for strengthening cancer prevention, detection, treatment, and patient care. Drafted in the context of the European Parliament’s 2022 Resolution on strengthening Europe in the fight against cancer, some of the goals set out include implementing new technologies, research and innovation, improving prevention and early detection, improving quality of life of patients, and fostering high standards of diagnosis and care (Council of Ministers, 2023[41]). The 2025 budget of the NHIF introduces full reimbursement for biomarker testing costs for cancer diagnosis (Republic of Bulgaria, 2025[21]).
Note: 1. Data refer to 2023. EU4 data for radiotherapy units refer to Czechia, Poland, the Slovak Republic and Slovenia.
Source: OECD Health Statistics 2025.
Further efforts to promote the health literacy of the population and enhance trust in healthcare would help improve disease prevention and health promotion
Low population health literacy, lack of awareness of vaccines, and increasing vaccine reluctance and hesitancy, in part due to rising conspiracy theories related to the COVID‑19 vaccine, contribute to low rates of vaccine coverage (see Chapter 4). About one‑third of people (36%) have poor or unsatisfactory level of health literacy (Baron-Epel et al., 2025[13]; Danailova Petrova-Geretto, Yanakieva and Vodenicharova, 2023[14]). People over the age of 55, those with a low social status and those with no (or few) educational qualifications have difficulty finding and understanding health information (Garov and Popov, 2018[15]). The trust of Bulgarian citizens in various institutions, structures and social groups of public importance is relatively low. The “Plus me” initiative on the website of the Ministry of Health was developed to fight against intentional and non-intentional occurrences of false information, namely misinformation and disinformation, respectively. This programme gathers evidence‑based information regarding vaccination and screening and shares it through the official website with the population. Bulgaria is planning a policy dialogue in June 2025 in collaboration with the OECD, European Observatory on Health Systems and Policies and experts from other countries on promoting the health literacy of the population to intensify its efforts on prevention and promotion activities.
Bulgaria should strengthen its primary care and shift towards more people‑centred, co‑ordinated and continuous care
General practitioners are independent under the NHIF and own their own practices, operating in individual or group practices. While general practitioners serve as gatekeepers to the majority of the population, children and pregnant women have direct access to paediatricians and gynaecologists. Patients can freely choose their primary and specialist healthcare providers. Primary care is underdeveloped, under resourced and undervalued. Despite reforms aiming at strengthening primary care, the Bulgarian healthcare system remains hospital centric. There is notable shortage of general practitioners and nurses (see Chapter 3 and 4). Bulgaria’s current legislation limits the role of general practitioners and, consequently, primary care, regarding access to diagnostic technologies, point-of-care, and ability to prescribe certain medicines (such as statins). General practitioners face a heavy workload of administrative tasks. This broadens the imbalance between the first and specialised levels of care and the ability to diagnose and treat diseases early and at lower severity. Quarterly quotas control the volume of services by limiting the number of referrals that general practitioners may write. When a quota is reached, patients must wait, choose to go directly to hospital emergency departments, or pay out-of-pocket to access services without referral. The connection and co‑ordination between hospitals and primary care are not well-established.
The 2030 National Health Strategy aims to strengthen primary care through various actions. The 2021-2027 National Plan for Improving the Accessibility and Capacity of Primary Outpatient Medical Care and Ensuring a Balanced Territorial Distribution of Medical Care and Health Care in the Republic of Bulgaria aim to build a national plan to address the shortage of primary care professionals. The NRRP addresses improving access to primary and outpatient care, including the creation of a health and social advisory service aimed at improving the health of the population and promoting a healthy lifestyle, the prevention of chronic conditions and supporting access to specialised medical care. Meanwhile, Investment 7 “Development of outpatient care” seeks to modernise primary care through three components: 1) the construction of a National Interdisciplinary Centre for Comprehensive Screening, 2) the construction of a modern material and technical base, and provision of medical equipment and infrastructure for outpatient clinics and medical and social advisory units, and 3) the development of a digital platform and services to support the diagnosis and treatment of major diseases such as cardiovascular and cerebrovascular diseases and diabetes. The main objective is to improve the access to and capacity of the outpatient care system and, consequently, population health.
Bulgaria should intensify its efforts to strengthen primary care and provide adequate organisational and financial mechanisms. Beyond financial incentives for medical students, further efforts are needed to retain existing primary care health workforce, notably in underserved areas. Increasing capacity, role and responsibilities of primary care professionals is essential to enhance job satisfaction and the sense of being valued. While information continuity and co‑ordination are developed through the NHIS, organisational and professional integration with hospitals and social care services need to be strengthened through appropriate governance mechanisms.
Beyond investments on hospital infrastructures, strong efforts are needed to improve efficiency and develop quality management systems in hospital care
The healthcare system is hospital-centric with high number of beds and hospitalisation rates (see Chapter 2). Public hospitals are multi-profile (with at least two specialised wards) or specialised (usually gynaecological, surgical, orthopaedic, ophthalmological, paediatric, or psychiatric). Each district has a large multi-profile hospital, co‑owned by the state and the district municipalities. Despite this, the hospital structure in Bulgaria is characterised by overcapacity, fragmentation, and known territorial and structural imbalances, which negatively affect its efficiency. The available hospital infrastructure is unevenly distributed across the country, with an overconcentration of hospital structures in the largest cities and a lack of capacity to meet basic needs for hospital care in small towns. There is an inefficient structure of hospital beds with a preponderance of beds for active treatment and a low supply of beds for long-term care and palliative care. Efforts continue to shift selected services from inpatient to outpatient settings. In 2016, Bulgaria began to shift selected services from inpatient to outpatient settings for specific conditions, amending some clinical pathways that previously required a hospital stay to ambulatory settings. Conditions affected included peritoneal dialysis, systematic drug treatment for malignant solid tumours and haematological diseases, most minor surgical procedures, and invasive diagnostic tests. Despite these efforts, Bulgaria’s hospital sector has grown, mainly due to private sector expansion. The NRRP includes a major investment proposal (EUR 310 million) to modernise state hospital facilities, as well as diagnostic and medical equipment. Bulgaria can increase the efficiency in hospital care by freeing up financial, material, and human resources that can be redirected to develop outpatient care and improve primary and preventive care (see Chapter 3).
Progress on measuring and assuring quality of care in Bulgaria has been slow and limited. According to the Health Act, the quality of medical care is based on medical standards for individual medical specialties, approved by regulations of the Minister of Health and the Rules of Good Medical Practice, developed by professional organisations of doctors and dentists. The medical standards define the minimum mandatory requirements for the structures for the implementation of the activities in certain medical specialties or the implementation of individual medical activities to ensure quality prevention, diagnosis, treatment, rehabilitation, and healthcare for the patient. They contain the basic characteristics of the medical specialty/medical activity; requirements for the medical specialists carrying out activities in the relevant medical specialty, requirements for the implementation of the activities in the medical specialty in medical facilities and the criteria for the quality of the performed activities by levels of competence. The control over the activity of medical institutions, medical activities and the quality of medical care is carried out by the Medical Supervision Executive Agency, which is a secondary authority with a budget to the Ministry of Health.
Bulgaria lacks a quality management system built on reliable indicators and monitoring mechanisms. Previous attempts to develop and quality and safety indicators have not been successful, and there is no medical error reporting system to ensure patient safety (European Observatory on Health Systems and Policies, 2024[16]). The implementation of the NHIS unlocks the potential of a wealth of health data to monitor, assess and improve. However, data need to be guided through reliable indicators to provide actionable information for health system performance assessment and improvement.
Bulgaria should improve monitoring and reporting of nosocomial infections
Healthcare associated infections (HAI), also known as nosocomial infections, are infections acquired while receiving healthcare that were absent upon admission. Antibiotic-resistant bacteria often cause HAIs. According to the European Centre for Disease Prevention and Control (ECDC), the average prevalence of HAI was 6.8% in EU countries in 2022, while the prevalence was 3.7% in Bulgaria, one of the lowest in the EU (European Centre for Disease Prevention and Control, 2024[17]). However, due to the small sample size, the representativeness might not be fully achieved in Bulgaria, therefore, the results should be interpreted with caution (European Centre for Disease Prevention and Control, 2024[18]). The country shows unfavourable levels of infection, prevention, and control capacity (e.g. infection prevention and control nurses, beds with alcohol based handrub dispenser) compared to EU countries, suggesting that the low HAI prevalence could be related to under-reporting of cases rather than better performance. The country requires hospitals to report nosocomial infection rates to inform the surveillance system for communicable diseases and to report to the ECDC. Data on nosocomial infections are partially collected according to the national legislation. For example, less than 30% of hospitals which participated in the ECDC survey reported participating in a national or regional network for the surveillance of surgical site infections or HAIs in intensive care units or Clostridium difficile infections (European Centre for Disease Prevention and Control, 2024[18]). Further improvements are needed to automate the surveillance and increase reporting by hospitals.
Note: Data refer to 2022. Refers to EU and European Economic Area (EEA) countries. 🡹 indicates better performance than EU/EEA mean/median, and 🡻 indicates worse performance than EU/EEA mean/median.
Source: Adapted from the country factsheet of Bulgaria published with the Point Prevalence Survey of Healthcare‑Associated Infection and Antimicrobial Use In Acute Care Hospitals 2022-2023 report (ECDC, 2024).
Clinical pathways create inefficiencies in hospital care, introduction of innovative payment models can encourage efficiency, effectiveness and quality
The delivery of specialised hospital care is based on the concept of clinical pathways, which were introduced in 2000 (Ganova-Iolovska and Geraedts, 2008[19]). Clinical pathways were initially conceptualised as a tool to improve care quality in patient services. The clinical pathway consists of requirements and guidelines for the behaviour of medical specialists as determined by the National Framework Agreement for medical activities and define the type and scope of the regulation in relation to patients with certain diseases requiring hospitalisation and a continuous hospital stay minimum of 48 hours. There were almost 300 clinical pathways in 2017, while the basic benefits package included more than 250 clinical pathways requiring a hospital stay of no less than 48 hours. These cover various medical specialties like surgery and specific treatments or conditions, such as operative interventions for soft and bone tissue infections, hernia repairs, diagnosis and treatment of hepatobiliary system diseases, or prolonged drug treatment for malignant solid tumours. Clinical pathways are determined by ordinances from the Ministry of Health, particularly Ordinance No. 9 of 2019 concerning the package of health activities guaranteed by the NHIF (OECD/European Observatory on Health Systems and Policies, 2021[20]). In 2021, three ordinances were adopted to amend and supplement this ordinance. Regulatory changes have, for example, created opportunities for patients with certain oncological diseases to access robot-assisted surgical treatment within the NHIF package via clinical pathways. Recently, some pathways have been divided by age groups, distinguishing between patients under 18 and over 18. The clinical activities lasting up to 24 hours, which are provided to patients within the framework of their hospital stay are addressed in the “clinical procedures” package since 2018.
Clinical pathways are primarily used for resource allocation purposes. Hospitals primarily receive funding through case‑based payments determined by clinical pathways. These payments are specified in the National Framework Contract and are negotiated between the NHIF and the Bulgarian Physicians Union. However, in its current form, they result in various inefficiencies. For example, regardless of the condition, length of hospital stay must always be at least two days for all clinical pathways if it is to be reimbursed by NHIF. In addition, hospitals sometimes need to adapt clinical pathways for the patients, yet NHIF only pays what has been agreed on historically at the beginning of the year. This might result in underpayment to hospitals compared to what has been delivered regarding the care services. In this regard, Bulgaria should introduce new design for payment systems that encourage efficiency, effectiveness and quality such as episode‑based bundled payments. Transitioning to innovative payment models will require aligning incentives across providers, expanding the scope of covered services, and embedding quality and outcome monitoring.
Mental health care remains hospital centric, stronger investments are needed to build infrastructures and capacity in community care settings
Mental health care in Bulgaria has been provided mainly at hospital settings, which are historically located outside the populated areas and are not in accordance with the administrative division of the country (Stoyanov and Nakov, 2023[21]). Patients were usually treated in these institutions, staying apart from their families and communities and disrupting their social lives. Mental healthcare in Bulgaria is not properly integrated with other health and social care services, underlining the lack of holistic approach. The 2021-2030 National Strategy for Mental Health of the People of the Republic of Bulgaria (Council of Ministers, 2022[22]) provides measures to move towards more person-centred approaches with the development of the network of psychiatric care facilities. Within these efforts, the National Mental Health Council under the Council of Ministers was established in 2022 as a permanent advisory body to the Council of Ministers. The National Mental Health Council, consisting of various institutions, is tasked for monitoring the progress on the implementation of the 2021-2030 National Strategy for Mental Health. In addition, the investment “Modernisation of Psychiatric Care in Bulgaria” financed from the NRRP aims to improve infrastructures and medical equipment at state psychiatry hospitals and multi-specialty hospitals. So far, 18 mental care institutions have been under renovation. Further efforts focus on developing child psychiatry in the country. Bulgaria should step up its efforts to develop and organise residential, day and outpatient psychiatric care in the community, including equipping them with fully functioning and responsive community mental health teams. Care continuity and co‑ordination between different health and social care systems should be ensured for effective provision of mental health care.
Mental healthcare in Bulgaria is highly institutionalised, with 12 psychiatric hospitals providing inpatient care mostly at a considerable distance from patients’ homes. Outpatient specialist mental health services are provided by individual or group psychiatric practices, and by psychiatrist’s offices in diagnostic-consultative centres and medical centres. A network of 12 mental health centres throughout the country delivers comprehensive preventive, primary, outpatient and inpatient care and various social services since 2010, primarily in urban areas. Municipalities provide for psychosocial rehabilitation, and material and social support for people with mental health disorders. Non-governmental organisations treat people with substance abuse issues. In 2023, there were 0.6 hospital beds per 1 000 population in psychiatric care, on par with the OECD average and slightly below the neighbouring EU5 average (0.7) (Figure 3.7).
Note: Data refer to 2023. 1. Data refer to 2022.
Source: OECD Health Statistics 2025.
The 2021-2030 National Strategy for Mental Health of the People of the Republic of Bulgaria provides measures to move towards more person-centred approaches (Council of Ministers, 2022[22]). The main objectives are deinstitutionalising mental health care and shift towards community settings, reducing morbidity and mortality from mental disorders, reducing the use of alcohol and narcotic substances and development of child psychiatry. In 2022, the National Mental Health Council was established under the Council of Ministers to have a co‑ordinated and comprehensive interministerial approach to mental health issues.
Integrated community care centres for children with disabilities face implementation challenges
Since 2018, Bulgaria has set up 12 integrated community care centres to tend to the needs of children with disabilities and chronic diseases, namely the Centre for Comprehensive Services for Children with Disabilities and Chronic Diseases. The objective is to provide comprehensive, integrated care services to children in a community setting. The funding of these centres is provided by the state budget, through the budget of the Ministry of Health. General practitioners, hospitals, or paediatricians can refer patients to these centres. The Centre for Comprehensive Services for Children with Disabilities and Chronic Diseases is equipped with multidisciplinary teams. For diagnostic, treatment and rehabilitation activities in the outpatient unit, the teams consist of a doctor, psychologist and social worker, and depending on the specific case, other medical and non-medical specialists are also included in the team. For the inpatient unit, the multidisciplinary teams include doctors, psychologists, nurses, midwives, rehabilitators, and other healthcare specialists, and depending on the specific case, non-medical specialists – speech therapists, physiotherapists, social workers, etc. The multidisciplinary team assesses the child’s needs and develops an individual medical and social plan for the necessary diagnostic, treatment and rehabilitation activities and supporting non-medical activities and services during the child’s stay in the medical facility, as well as when using mobile services. To monitor the implementation of the individual medical and social plan, a responsible specialist with appropriate qualifications, tailored to the child’s illness, is appointed, who performs the functions of head of the multidisciplinary team and is responsible for organizing the activities for the implementation of the plan. The multidisciplinary team meets periodically to discuss patient cases taking into account the progress in the child’s development and formulating new goals and objectives. The reporting period cannot be longer than three months. Main challenges exist in ensuring adequate workforce and retaining care providers. Bulgaria should increase its efforts to continue the implementation of the remaining 16 centres with adequate workforce planning, as the original plan was to have one comprehensive centre for each region.
Long-term care in Bulgaria is underdeveloped with most care being provided by informal carers
In Bulgaria, the governance of long-term care (LTC) is shared between the Ministry of Health, responsible for medical services and health policy including hospital care for long-term treatment and palliative care, and the Ministry of Labour and Social Policy, which oversees social services and support for dependent individuals, with local municipalities managing service delivery. Bulgaria’s LTC system is underfunded, with care being provided predominantly by informal providers, specifically households. In 2023, Bulgaria spent 0.4% of its GDP in LTC, more than four times lower than the OECD average (1.7%) and half the neighbouring EU5 average (1%) (Figure 3.8). The vast majority of health spending is attributed to households, comprising 94.4% of all LTC spending and standing in stark contrast with the OECD average of 9.6%. Nursing homes take up the remainder 5.1%, with hospitals accounting for less than 1% of LTC spending.
Note: Data refer to 2023. 1. Countries not reporting social LTC. 2. 2022 data. The category “Social providers” refers to providers where the primary focus is on help with Instrumental Activities of Daily Living (IADL) or other social care. In Panel B, EU4 data refer to Czechia, Poland, the Slovak Republic, and Slovenia.
Source: OECD Health Statistics 2025.
In its current state, Bulgaria is currently in the process of developing its long-term care infrastructure. The network of state funded social services includes a total of 1 878 services with the capacity to support 65 058 users. Among them, 715 services are dedicated to day care, counselling, therapy, rehabilitation, and other forms of assistance for children and adults, 750 residential care services accommodate both children and adults in protected housing, transitional housing, and family-type accommodation centres and Assistant Support is available across 263 municipalities. In 2023, there were 2.6 long-term care beds per 1 000 population aged 65 years and over, the lowest when compared to OECD countries and almost 20‑fold lower than the OECD and neighbouring EU5 averages (41.2 and 40.8, respectively) (Figure 3.9). Hospital beds represented 57.8% of all LTC beds, five times higher than in the OECD and neighbouring EU5 countries (5.3% and 8.8%, respectively). Increasing the number of long-term care beds, improving social services, and improving home care is within the goals of the 2030 National Health Strategy.
1. Latest data from 2021-2022. 2. Data only includes beds in institutions.
Source: OECD Health Statistics, 2025.
The National Development Programme 2030 and the 2030 National Health Strategy include policies to stimulate medical institutions to develop activities for long-term treatment and palliative care, including by restructuring active hospital beds to cover the growing need for care as a result of population ageing. Part of the process of modernisation involves deinstitutionalising care by bringing LTC closer to communities. Regarding institutional care facilities, there are 82 homes for elderly persons with 5 598 places, which are undergoing structural reforms to align with modernised care standards. Furthermore, 68 homes for people with disabilities with 4 395 places are currently undergoing a phased closure by 2035 as part of the national deinstitutionalisation strategy.
In Bulgaria, 24% of people aged 65 reported having severe or some limitations in daily activity in 2021, higher than the OECD and neighbouring EU5 averages (22%). Demand for LTC, as in many OECD countries, will likely rise with an increasingly aged population: in 2023, 24% of people was aged 65 or over, which is expected to reach 30% by 2050. This may result in increased pressure on the LTC system. Bulgaria has taken actions towards the deinstitutionalisation of care for the people with disabilities and the elderly. This process is legally regulated in the Social Services Act and is implemented through the adopted strategic documents – the National Strategy for Long-Term Care (the Strategy), the 2018-2021 Action Plan for the implementation of the National Strategy for Long-Term Care and the 2022-2027 Action Plan for the implementation of the National Strategy for Long-Term Care.
1. 2017-2019 data.
Source: SHARE wave 9 (2021 22); ELSA, wave 9 (2019), for the United Kingdom; HRS (2018) for the United States; KLoSA (2018) for Korea; SSJDA (2017) for Japan, TILDA wave 5 (2018) for Ireland.
Palliative care is insufficient to meet the needs and deepening inequalities, calling for increased investment
Palliative care is covered in the NHIF and provided only in the centres with trained specialists. The palliative care pathway includes basic medical activities to relive the patient’s condition. In total, 25 hospitals in Bulgaria have signed a contract with the NHIF for provision of palliative care for patients with oncological diseases (EAPC, 2025[23]) In 2021, Bulgaria had 47 hospices, funded through private mechanisms, with 1 175 beds providing palliative care to people with cancer and other chronic conditions (IPAAC, 2021[24]). According to the Ministry of Health, there are 29 hospices which have a contract with the NHIF for palliative care, 117 for long-term treatment after the acute stage of stroke, 53 for long-term treatment after the acute stage of heart attack or after cardiac intervention, 82 for long-term treatment after surgical intervention with large and very large volume and complexity and with residual health problems. According to the Executive Agency Medical Supervision registry, 52 hospices are registered to the Public Register of Outpatient Care Facilities and Hospices (National Health Information System, 2025[25]).
However, these positive developments have been insufficient. Palliative care is uneven, uncoordinated, insufficient and not well integrated across the healthcare system, mainly as a result of limited public investment and low service capacity (OECD, 2023[8]; IPAAC, 2021[24]). In Bulgaria, 15% of people who died aged 65 and used palliative care or hospice before death, while it rises up to 65% in the OECD countries (OECD, 2023[26]). Palliative care patients are mainly cared by their families, mainly due to financial reasons (IPAAC, 2021[24]), which is insufficient to cover the complex needs of end-of-life care. Estimates show that only 5% of all terminally ill cancer patients in Bulgaria received palliative care in 2020. In the Global Atlas of Palliative Care (WHPCA, 2020[27]) Bulgaria is defined as belonging among the lowest 25% of countries in terms of development of palliative care activities in several locations, with growth of local support in those areas; multiple sources of funding; availability of morphine; several hospice palliative care services from a range of providers; and provision of some training and education initiatives by hospice and palliative care organisations. There are no specialisations in palliative care for either doctors or nurses (Despotova-Toleva and Toleva-Nowak, 2021[28]). Typically, intensive care specialists, medical oncologists, general practitioners and internal medicine specialists provide end-of-life care. The shortage of nurses in Bulgaria is the biggest challenge to the quality of palliative care. Many privately provided initiatives exist, but they are not funded through the public health insurance scheme, deepening inequalities.
Recognising this growing need, the National Development Programme Bulgaria 2030 and the 2030 National Health Strategy include policies to stimulate medical institutions to develop activities for long-term treatment and palliative care, including by restructuring active hospital beds to cover the growing needs of the population. Bulgaria should strengthen its efforts to increase access to palliative care by developing palliative care infrastructures, training health workforce, and ensuring their equal distribution.
References
[13] Baron-Epel, O. et al. (2025), “Pathways of how health literacy and social support are associated with health outcomes in 17 European countries: Results of mediation analyses”, Public Health, Vol. 241, pp. 12-18, https://doi.org/10.1016/j.puhe.2025.01.032.
[22] Council of Ministers (2022), Националната стратегия за психично здраве на гражданите на Република България 2021–2030, https://www.strategy.bg/StrategicDocuments/View.aspx?lang=bg-BG&Id=1568.
[14] Danailova Petrova-Geretto, E., A. Yanakieva and A. Vodenicharova (2023), “Health literacy: A call for action for a just and egalitarian society”, SCIENCE International Journal, Vol. 2/1, pp. 37-40, https://doi.org/10.35120/sciencej020137d.
[28] Despotova-Toleva, L. and N. Toleva-Nowak (2021), “Narrative review of home care for palliative patients in general practice”, Annals of Palliative Medicine, Vol. 10/12, pp. 13009-13023, https://doi.org/10.21037/apm-2021-01.
[23] EAPC (2025), EAPC Atlas of Palliative Care in the European Region 2025, https://www.unav.edu/documents/30448903/167090281/Bulgaria.pdf/.
[3] ERGO Network (2022), ROMA access to adequate healthcare and long-term care, https://ergonetwork.eu/wp-content/uploads/2022/11/Ergo-2022-access-healthcareWEB.pdf.
[17] European Centre for Disease Prevention and Control (2024), Key indicators of the point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals- Country factsheet: Bulgaria, https://www.ecdc.europa.eu/en/publications-data/country-factsheet-bulgaria.
[18] European Centre for Disease Prevention and Control (2024), Point prevalence survey of healthcareassociated infections and antimicrobial use in European acute care hospitals, ECDC, https://www.ecdc.europa.eu/sites/default/files/documents/healthcare-associated-point-prevalence-survey-acute-care-hospitals-2022-2023.pdf.
[16] European Observatory on Health Systems and Policies (2024), Bulgaria: Health system summary, https://eurohealthobservatory.who.int/publications/i/bulgaria-health-system-summary-2024.
[2] Eurostat (2025), Self-reported unmet needs for dental examination by sex, age, main reason declared and degree of urbanisation, https://doi.org/10.2908/HLTH_SILC_22.
[1] Eurostat (2025), Self-reported unmet needs for medical examination by sex, age, main reason declared and income quintile, https://doi.org/10.2908/HLTH_SILC_08.
[11] Eurostat (2022), Self-reported last breast examination by X-ray among women by age and income quintile, https://doi.org/10.2908/hlth_ehis_pa7i.
[10] Eurostat (2022), Self-reported last cervical smear test among women by age and income quintile, https://doi.org/10.2908/hlth_ehis_pa8i.
[19] Ganova-Iolovska, M. and M. Geraedts (2008), “Clinical pathways – the Bulgarian approach”, Journal of Public Health, Vol. 17/3, pp. 225-230, https://doi.org/10.1007/s10389-008-0239-0.
[15] Garov, S. and T. Popov (2018), “Health literacy of the population in Bulgaria – policies, programs and guidelines for improvement”, Trakia Journal of Science, Vol. 16/Suppl.1, pp. 211-214, https://doi.org/10.15547/tjs.2018.s.01.042.
[24] IPAAC (2021), Palliative care pathway for chronically ill patients, https://www.ipaac.eu/res/file/roadmap/id047.pdf.
[4] Kostadinov, S. et al. (2023), “Restrictions on access to medical care for the uninsured in Bulgaria”, European Journal of Public Health, Vol. 33/Supplement_2, https://doi.org/10.1093/eurpub/ckad160.1113.
[9] Ministry of Health (2025), Plus Me: HPV programme, https://plusmen.bg/bg/national-programs/hpv.
[25] National Health Information System (2025), Public Register of Outpatient Care Facilities and Hospices (PRHC), https://opendata.his.bg/lzibph/.
[7] OECD (2025), Does Healthcare Deliver?: Results from the Patient-Reported Indicator Surveys (PaRIS), OECD Publishing, Paris, https://doi.org/10.1787/c8af05a5-en.
[6] OECD (2024), Rethinking Health System Performance Assessment: A Renewed Framework, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/107182c8-en.
[8] OECD (2023), EU Country Cancer Profile: Bulgaria 2023, EU Country Cancer Profiles, OECD Publishing, Paris, https://doi.org/10.1787/f6915046-en.
[26] OECD (2023), Time for Better Care at the End of Life, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/722b927a-en.
[12] OECD/European Commission (2025), EU Country Cancer Profile: Bulgaria 2025, EU Country Cancer Profiles, OECD Publishing, Paris, https://doi.org/10.1787/c6533317-en.
[20] OECD/European Observatory on Health Systems and Policies (2021), Bulgaria: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris, https://doi.org/10.1787/c1a721b0-en.
[5] Republic of Bulgaria (2020), Medicinal Products in Human Medicine Act, https://www.bda.bg/images/stories/documents/legal_acts/20210208_ZLPHM_English.pdf.
[21] Stoyanov, D. and V. Nakov (2023), “The mental health system in Bulgaria: socialist heritage and prospects”, Consortium Psychiatricum, Vol. 4/2, pp. 115-124, https://doi.org/10.17816/cp8631.
[27] WHPCA (2020), Global Atlas of Palliative Care, https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/palliative-care/whpca_global_atlas_p5_digital_final.pdf?sfvrsn=1b54423a_3.