This chapter summarises the in-depth assessment conducted as part of Bulgaria’s accession review and presents key recommendations to enhance the performance of the health system across critical dimensions, including sustainability, efficiency, quality, access, and resilience. Bulgaria’s health system has made notable progress, but health status and performance remain low relative to OECD countries. To be adequately prepared to meet the 21st century health challenges, Bulgaria would need to sustain its efforts and accelerate the transition towards a more sustainable and resilient health system, specifically by reducing inefficiencies, cutting wasteful spending, strengthening primary care and prevention, and improving access to care.
OECD Reviews of Health Systems: Bulgaria 2026
Abstract
Bulgaria has seen improvements in life expectancy since 2000, reaching 75.8 years in 2023, which is below the OECD average of 81 years. Maternal deaths during pregnancy or childbirth have improved in the last decade, decreasing by about 31% (10.3 deaths per 100 000 live births in 2010 to 7.1 deaths in 2020), and infant mortality has halved between 2011 and 2024. Despite progress, health outcomes and health system performance are worse and display larger inequalities than in most OECD countries, as reflected in most OECD indicators on health status, risk factors for health, and quality of care (Figure 1.1). To address these challenges, Bulgaria has recently developed a strategic vision to achieve a more effective, integrated, and resilient healthcare system, notably with the adoption of the National Health Strategy 2030.
Bulgaria became an OECD accession candidate in 2022. As part of the accession process, the OECD conducted a review of the Bulgaria’s health system, policies, and practices. This chapter summarises the in-depth assessment and formulates recommendations to enhance the performance of the health system across critical dimensions, including sustainability, efficiency, resilience, quality and access.
Strengthening primary care would help Bulgaria respond to epidemiological shifts that are occurring due to an ageing population and the increased prevalence of diseases. Bulgaria has already taken some initiatives to boost primary and community care, but its healthcare system still heavily relies on hospital services. Bulgaria has 8.2 hospital beds per 1 000 population, almost double the OECD average of 4.3. Hospital discharge rates are above the OECD average (325 and 129 per 1 000 population, respectively). While hospitals account for more than a third of health spending (37%), ambulatory care accounts for only 15%. The referral system is weak with many patients turning to emergency and hospital care for medical needs that could be dealt with at the primary care level. Bulgaria could intensify its efforts to strengthen the referral system and define clearer criteria and standards, as well as improve roles and responsibilities of general practitioners in diagnosis, management and treatment of conditions that can be managed in primary care. Nurses and community health workers (Health Mediators) could be empowered and encouraged to be more actively involved in delivering primary and preventive care services, including health promotion, patient education and chronic disease management, and co‑ordination of patient care with general practitioners.
While progress has been made in infection prevention and control, challenges remain in Bulgaria’s public health and prevention policies, particularly those targeting chronic conditions and associated risk factors. Avoidable mortality rates are above the OECD average (562 and 246 deaths per 100 000 population, respectively). Mortality from preventable causes, which could be avoided through effective public health and primary prevention strategies, are more than twice the OECD average (378 and 166 deaths per 100 000 population, respectively). A significant share of mortality (36%) is attributable to behavioural and environmental risk factors. Dietary risks alone account for one fifth of all deaths, well above the OECD average (19% and 12%, respectively). At 29%, smoking rates in Bulgaria are higher than all OECD countries (15%). Moreover, the share of people aged 15 and over who smoke daily has remained unchanged between 2008 and 2019. The leading causes of death are diseases of the circulatory system and cancer, together responsible for 60% of all deaths.
Note: A green dot stands for the best performing OECD country, whereas a red dot stands for the least performing OECD country. The exception of the colour-coded groups is for health resources, where indicators cannot be classified as showing better or worse performance. For this reason, lighter and darker shades of blue signal whether a country has less or more resources than the OECD average. Data refer to 2022 or the nearest year. The EU5 average is calculated across five EU neighbouring countries (Czechia, Hungary, Poland, the Slovak Republic and Slovenia).
Source: OECD Health Statistics 2025; EU-SILC (2023); ECDC (2021).
The National Development Programme 2030 and the National Plan for Recovery and Resilience (NPRR) address preventive care. Yet, more efforts are needed to increase participation in prevention activities tackle misinformation and disinformation and promote health literacy and trust in the healthcare system. Bulgaria should intensify its efforts to encourage healthier lifestyles through a mix of fiscal, regulatory and communication policies. These policies could consist of, but are not limited to, increasing taxation on tobacco, alcohol and products high in fat, sugar and salt, introducing simplified front-of-pack food labelling, plain packaging for tobacco products with text/graphic warning labels, developing health literacy programmes and expanding school-based health education programmes. Further efforts to strengthen the role of primary care professionals and patient representatives in prevention and health promotion are needed by supporting their engagement in community outreach and mobilising their long-term relationship with patients to promote health literacy and build trust in the healthcare system.
Bulgaria’s capacity for the resilience and preparedness of the health system to prepare for and respond to health emergencies and other crisis was severely tested during the COVID‑19 pandemic. Bulgaria had the highest excess mortality rates1 (+17.2%), and the highest age‑standardised excess death rates (24.7 deaths per 10 000 population) across the European Union countries over the period of 2020‑2023. Antibiotic resistance is an important public health concern with antibiotic consumption of 22 daily defined doses per 1000 population per day, higher than any OECD country. Hepatitis C prevalence rates are high (0.9%), almost double the OECD average of 0.5%. The lack of epidemiological data about chronic hepatitis C cases undermines the potential for effective preventive policies. Beyond the COVID‑19 pandemic, Bulgaria has faced and responded to other shocks such as natural and climate‑related disasters (forest fires, floods and prolonged droughts during the summer in 2024, one of the hottest on record). Recognising the importance of strengthening pandemic preparedness and response, the Bulgarian NPRR for 2021‑2026 includes major investments in modernising hospital infrastructures, the national system for air emergency, and promoting the recruitment and retention of healthcare professionals in rural and remote areas. Bulgaria needs to intensify its efforts to develop broader monitoring capacities, by collecting and analysing granular data, to prepare for future shocks to the health system and manage the healthcare needs of the Bulgarian population, paying particular attention to vulnerable groups.
Mental health disorders are the second leading cause of years lived with disability, though the prevalence of mental health disorders was lower than the OECD average (14 200 cases and 16 099 per 100 000 population, respectively). Mental healthcare relies heavily on institutional care and pharmacotherapy. Mental healthcare is insufficiently integrated with other health and social care services, highlighting the fragmentation in the system. 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. Within these efforts, Bulgaria created an inter-institutional body (the National Mental Health Council) under the Council of Ministers as a permanent advisory body to the Council of Ministers, to monitor the progress on the implementation of the 2021-2030 National Strategy for Mental Health. In addition, “Modernisation of Psychiatric Care”, which is financed from the NPRR, aims to improve infrastructures and medical equipment at state psychiatry hospitals and multi-specialty hospitals. Bulgaria needs to continue its efforts to improve the mental health of the Bulgarian population by strengthening the prevention of poor mental health, including alcohol and substance use disorders. It also needs to continue investing in outpatient and community mental health care services and equipping them with multiprofessional practices.
Since 2018, Bulgaria has started establishing a new type of medical facility – Centre for Complex Services for Children with Disabilities and Chronic Diseases – across the country. These centres provide outpatient services including diagnostics, treatment, and medical and psychosocial rehabilitation. In addition to mobile services, in certain centres, inpatient long-term treatment up to three months, rehabilitation up to six months, and specialised palliative care for children are also provided. The centres are financed directly by the budget of the Ministry of Health and are freely accessible for children with disabilities and their parents. To date, 12 centres have been established, and Bulgaria needs to continue its efforts to establish the remaining 16 centres with adequate and sustainable workforce planning, as the original plan was to have one comprehensive centre for each region.
As part of its efforts to strengthen the governance of the health system, Bulgaria has implemented reforms to digitalise the healthcare system and develop the National Health Information System (NHIS). To achieve this, a health information portal was developed in 2020 with unified electronic health records, nomenclatures, electronic prescriptions, and electronic referrals. The NHIS collects information from all sectors of healthcare including hospitals and general practitioners that allow monitoring and control of healthcare. The NHIS currently covers all healthcare professionals across healthcare settings and serves as a data repository. Data are linkable and available for decision making purposes and secondary use, however access to data is hampered by administrative procedures. Further integrations with other existing systems such as National Health Insurance Fund (NHIF), the Bulgarian Drug Agency, and the National Council on Prices and Reimbursement of Medicinal Products have recently been achieved. A mobile application (eZdrave) allowing patients to access their medical files has also been developed, where patients can see the results of their examinations, laboratory tests, as well as preventive activities such as vaccinations.
To improve health outcomes and care experiences and move towards a more people‑centred healthcare system, Bulgaria should invest in robust infrastructures for health system performance assessment and quality management, with stronger accountability and transparency. To enable data-driven policymaking while also fostering greater accountability and transparency within the healthcare system and managing expectations regarding its performance, Bulgaria should invest in developing a quality management system that encompasses valid and reliable quality indicators and mechanisms for monitoring and continuous quality improvement. Recent developments with the NHIS provides opportunities to systematically collect data and use the results to enhance learning healthcare systems and data‑informed policymaking.
Bulgaria currently lacks robust quality management systems built on relevant and reliable indicators and monitoring mechanisms. The assessment of healthcare system performance and quality in care relies heavily on process indicators such as vaccination rates and on inputs such as the number of healthcare professionals or hospital beds. Bulgaria should put significant efforts on further strengthening their data infrastructure to develop relevant indicators for quality of care, people‑centredness of healthcare and patient safety. Drawing from the OECD’s Renewed Framework of Healthcare System Performance Assessment and leveraging the data from the NHIS, further efforts should focus on identifying priority areas for performance assessment in the Bulgarian healthcare system and developing an agreed set of indicators to monitor progress. These priority areas could include measuring quality of care, including patient-reported experiences and outcomes, and patient safety. Participating in international initiatives such as OECD’s Quality and Outcomes benchmarking work and the Patient-Reported Indicator Surveys (PaRIS) will help identify areas for improvement from the patients’ perspectives while providing opportunities for cross-country learning.
Bulgarian efforts to monitor and regularly report indicators need to be situated within a wider focus on enhancing accountability and transparency. While Bulgaria already publishes annual public reports on health status and broader performance assessment data, information on the quality and safety of care such as avoidable admissions, patient safety events and patient-reported outcome measures, should be reported regularly to policymakers, healthcare professionals, and the public to promote a culture of improvement. Such initiatives will not only support informed choices but also contribute to strengthening public trust. Feedback mechanisms to decisionmakers should be established to inform policy adjustments and quality improvement initiatives and provide a clear picture of the strengths and weaknesses of the healthcare system, while also setting expectations and accountability for progress made over time.
Bulgaria can seek ways to increase public funding for healthcare while enhancing spending efficiency and long-term system sustainability. In 2023, 7.7% of Bulgaria’s GDP was spent on health, below the OECD average of 9.2%. The gap widens when looking at health spending per person, with Bulgaria spending USD 3 187 per capita in purchasing power parity (PPP) terms, almost half the OECD average (USD 5 565). While this is similar to OECD countries with a comparable GDP per capita such as Costa Rica and Türkiye, it still stands below the neighbouring EU5 countries – OECD countries with a comparable income level in the same region: Czechia, Hungary, Poland, the Slovak Republic, and Slovenia (USD PPP 4 020 per capita). Furthermore, public spending in 2022 represented 63.5% of total spending, which is below both the OECD and neighbouring EU5 averages (75.3% and 77%, respectively).
That said, room for increasing public spending on health is somewhat limited at present. Health spending already represents 12% of the government budget. Bulgaria should therefore optimise existing budgets, for example by improving performance budgeting instead of relying on the current historical budgeting approach and by implementing spending reviews, and cutting waste in health systems, for example by reducing low-value care and operational waste. Given its position as the main purchaser of care, the NHIF could take on a more strategic role, for example by using its purchasing power to promote a shift from expensive inpatient care to outpatient and daycare and by promoting rational medicine use, notably antibiotics. The NHIS could further enhance transparent tracking of volume and prices of health products and services, benchmarking of prescription activities across healthcare professionals and settings. Those efforts would help create efficiencies and fiscal space to expand coverage and reduce out of pocket payments. Looking forward, the country will face significant fiscal pressures linked to an ageing population and a high prevalence of chronic conditions. Improving efficiency in health spending is therefore essential, not only to sustain the system, but also to free up resources for improved access and financial protection.
By using resources more effectively, the Bulgarian health system can improve its ability to deliver safe, people‑centred and appropriate services, including access to preventive care and medical treatment, to all social groups in a transparent and timely manner. This includes reducing out-of-pocket payments, which currently account for one‑third (35%) of all health spending, with pharmaceuticals making the majority (69%). The government introduced a landmark pharmaceutical reform in April 2024 (OECD/European Observatory on Health Systems and Policies, 2025[1]). The policy provides 100% reimbursement for 56 essential cardiovascular medicines and heavily subsidises over 300 others. Early results are promising: nine months after implementation, the NHIF reported that an additional 30 000 people were effectively managing their conditions, with a corresponding decrease in hospitalisations for complications. The 2025 budget also introduced new measures, including full reimbursement for prescribed antibiotics and antiviral medications for children up to seven years of age and coverage of biomarker testing costs for cancer diagnosis. However, efforts are needed to steer patients towards generic bioequivalent products.
In Bulgaria, the NHIF reimburses outpatient medicines at a reference price per defined daily dose (DDD), typically aligned with the lowest available equivalent; when a higher-priced brand or generic is prescribed, patients pay the difference out-of-pocket (OECD/European Observatory on Health Systems and Policies, 2025[1]). Pharmacy-level substitution is not authorised, therefore when physicians prescribe a specific product, pharmacists must dispense that (branded or designated generic) product if available. This prescribing pattern sustains use of higher-priced brands and elevates out-of-pocket spending. Bulgaria needs to strengthen the implementation of International Non-proprietary Names prescription as well as dispensing. Partnering with healthcare and patient organisations and increasing learning and training opportunities with clear guidelines for prescribers and patients about the efficacy and safety of generic medicines are essential to achieve this.
Efficiency gains can also support investment in underserved areas, where access to healthcare is most limited. Around one in four people in Bulgaria (27%) live in rural areas, where access to healthcare and basic needs is more limited. Shortages of healthcare professionals, including general practitioners, nurses and other specialists, are prominent across regions, and are exacerbated in rural and remote areas. 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 (0.84 per 1 000 population), and a national average of 0.59 per 1 000 population, below the OECD average (0.84 per 1 000).
Bulgaria has already introduced measures to attract and retain healthcare professionals. The Ministry of Health has provided attractive conditions for postgraduate training to acquire a specialty. For example, state‑funded trainees in general practice are provided with a monthly salary from the budget of the Ministry of Health representing 2.5 times the minimum wage in the country for the entire period of their training. According to the Ministry of Health, the number of postgraduates in general practice has increased from 308 in 2022 to 571 in 2024. The project “Promoting specialisation in healthcare and in areas with a shortage of specialists” also encourages a more balanced distribution of healthcare professionals by providing financial incentives to postgraduates who are trained in a specialty with an established shortage of specialists and those who are trained in a specialty with the lowest provision of relevant specialists. In addition, through the National Map of Long-Term Health Needs, Bulgaria has introduced financial incentives to recruit and retain healthcare professionals in underserved areas. Bulgaria could further benefit from introducing new roles or positions for healthcare professionals, including nurses, assistant physicians and community pharmacists, to share tasks and address shortages of doctors in these regions. Promoting job satisfaction by enhancing the roles and responsibilities of healthcare professionals is an area that need to be addressed. Telemedicine is another lever to improve access to care in underserved areas. Teleconsultation services are currently not widespread and can be further expanded and upscaled at the national level. Availability of telemedicine with specialist referrals can support and attract primary care professionals by promoting effective and co‑ordinated patient management and improving working conditions.
To conclude, the Bulgarian healthcare system is characterised by a high degree of centralisation under a compulsory social health insurance scheme. While there have been significant improvements on health outcomes and healthcare system performance over the past decade, Bulgaria outcome measures remain well below those of other OECD countries with large disparities. Bulgaria continues to face significant challenges such as over-reliance on hospital care and an insufficient focus on prevention and public health, which are ill-adapted given the high prevalence of chronic conditions and unhealthy lifestyles; limited robust structures to assess and improve healthcare system performance; and high OOP payments and long-term fiscal sustainability challenges. Ongoing reforms, as outlined in the National Health Strategy 2030, address some of these issues by improving access, efficiency, and public health. Moving forward, strengthening primary and preventive care, investing in quality management systems, and strengthening health system financing and reducing out-of-pocket payments will be crucial next steps in making the Bulgarian healthcare system more efficient, people‑centred, and resilient.
Strengthening primary care, prevention, and managing of chronic conditions and risk factors for improved health promotion
Ensure close monitoring of implementation and progress in achieving objectives of 2030 National Health Strategy and the goals in the forthcoming National Programs for the Prevention of Chronic Non-Communicable Diseases. Strengthen national prevention programmes and strengthen primary prevention by introducing fiscal, regulatory and communication policies to address lifestyle risk factors such as tobacco consumption and unhealthy diets.
Promote population’s health literacy regarding healthy living and prevention activities to increase participation in secondary prevention and health promotion activities and fight against misinformation and disinformation in health. Strengthen the role of primary care professionals and patient representatives in prevention and health promotion by ensuring dedicated time and resources, embedding measurable prevention goals in practice, and supporting their engagement in community outreach, peer education, and co-design of health initiatives.
Strengthen primary care by enhancing the referral system (for example by removing the quotas on referrals) and defining clearer criteria and standards. Strengthen and enable general practitioners to fully exercise the scope of their practice by supporting the diagnosis, management, and treatment of conditions suitable for primary care – through improved access to diagnostic tools and referral system, updated clinical protocols and training.
Develop long-term care services, workforce capacities and improve infrastructure in community settings and away from hospitals.
Strengthen capacity for crisis preparedness and response, including developing broader monitoring capacities and investing further in prevention and preparedness activities. Address antimicrobial resistance by monitoring and adding controls on the use of antibiotics. Increase public and healthcare professional awareness on the prescription and use of antibiotics.
Improving access, outcomes, and experiences of care
Expand coverage to uninsured populations and increase awareness among vulnerable groups to avoid foregoing care and promote care‑seeking behaviour.
Improve access to services in remote areas, such as by expanding the existing roles or creating new posts for healthcare professionals, including nurses, to address gaps in the supply of doctors and promote job satisfaction in these regions. Mobilise primary care professionals, including nurses and health mediators, to increase reach to vulnerable groups. Develop teleconsultation technologies and a comprehensive national system as part of interventions to address access issues in underserved areas.
Develop performance assessment and quality management systems and effective indicators to track quality by collecting broader performance assessment data. Develop relevant indicators to assess quality of care, people‑centredness of healthcare and patient safety. Enhance transparency and accountability through quality assurance mechanisms such as public reporting and feedback mechanisms.
Continue the efforts towards achieving the goal for community-based mental health care services strongly linked to primary care and integrated with wider health services. Strengthen the role of outpatient care, early detection and intervention and non-pharmacological treatment to tackle mental health needs.
Strengthen people‑centredness of the health system by institutionalising patient representation in policymaking, through meaningful engagement and systematically measuring patient-reported outcomes and experiences.
Leverage the opportunities provided by NHIS to systematically collect data to build learning health systems and data-driven policymaking. Mobilise the knowledge and experience of international initiatives such as the OECD’s Renewed Framework of Health System Performance Assessment, OECD’s Quality and Outcomes and Patient-Reported Indicator Surveys (PaRIS) to develop a more nuanced understanding of health system performance.
Improve patient ease of access to electronic health records stored in NHIS by streamlining security and identification processes. Work towards developing an integrated electronic health record easily accessible by all relevant parties, patients, and providers alike. Leverage the NHIS as an integrated hub for health data by introducing options for secondary data use, such as access by health researchers. Develop frameworks to facilitate access to data and reduce administrative burden.
Strengthen the use NHIS data to enhance transparent monitoring of the volume and prices of services and products as well as the prescription activities in different settings, supporting efforts to improve monitoring of resource use and efficiency.
Improving healthcare system efficiency, fiscal sustainability, and transparency
Ensure the level of health financing corresponds to the population’s health needs. Implement reform to create fiscal space to expand public spending capacity (such as reducing inefficiencies and using evidence‑based budget planning), especially to strengthen primary and preventive care and reduce out-of-pocket payments for outpatient services and essential medicines. Shift from historical budgeting towards target-based budgeting, encouraging rational allocation of resources towards improving value for money and performance targets.
Shift from expensive inpatient care to outpatient and daycare, considering opportunities to rationalise hospital capacity and look for opportunities to cut waste in the healthcare system, such as promoting primary and preventive care and decreasing the prescription of branded products through mandatory INN prescribing. Use the purchasing power of NHIF to encourage a shift from expensive inpatient care to outpatient and daycare where relevant and promoting rational medicine use, notably regarding antibiotics consumption. Strengthen primary care and reduce the reliance on hospital and specialised care by enhancing the general practitioners’ roles and responsibilities, including for diagnosis and treatment, such as by removing or easing limits on referrals.
Lower pharmaceutical out of pocket spending. Incentivise the prescription and use of generics and biosimilars that are fully covered by NHIF by raising awareness among patients and practitioners.
Adapt clinical pathways to promote appropriate lengths of stay, for example by removing mandatory minimum hospital stay requirement (such as a 48‑hours minimum), to reduce inefficient use of inpatient resources. Introduce innovative payment systems that encourage efficiency, effectiveness, and quality, such as episode‑based bundled payments.
Leverage the NHIS data to assess the different dimensions of the healthcare system performance such as efficiency, people‑centredness, equality and sustainability. Make the NHIF a strategic purchaser to encourage a shift from inpatient to outpatient care or to promote rational medicine use (such as antibiotics).
Strengthen efforts to tackle corruption by enhancing monitoring and checks, transparency, and public engagement, leveraging the NHIS to obtain relevant data.
References
[2] Morgan, D. et al. (2020), “Excess mortality: Measuring the direct and indirect impact of COVID-19”, OECD Health Working Papers, No. 122, OECD Publishing, Paris, https://doi.org/10.1787/c5dc0c50-en.
[1] OECD/European Observatory on Health Systems and Policies (2025), Country Health Profile 2025: Bulgaria, OECD Publishing/European Observatory on Health Systems and Policies, https://www.oecd.org/en/publications/2025/12/country-health-profile-2025-country-notes_7e72146d/bulgaria_242bb908.html.
← 1. Excess mortality, a measure of mortality over and above what could normally be expected for the period, show the impact – both direct and indirect – of COVID‑19 pandemic (Morgan et al., 2020[2]).