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, and infant mortality has halved between 2011 and 2024. Despite progress, health outcomes and health system performance are worse and display larger inequalities compared to most OECD countries, as reflected in most OECD indicators on health status, risk factors for health, and quality of care.
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. Recent reforms have showed promising results in addressing shortages of healthcare professionals, improving digitalisation of healthcare, and developing integrated care settings. First, the Ministry of Health has provided attractive conditions for postgraduate training for acquiring 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. Second, 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. Third, Bulgaria is establishing integrated facilities for children with disabilities and chronic conditions.
Despite these recent policy changes, Bulgaria faces important challenges that need to be addressed to improve population health, enhance access to healthcare, improve quality and safety of care and make the healthcare system more efficient and resilient. These challenges will intensify as the Bulgarian population ages, leading to a further increase in chronic conditions and fiscal pressure on the healthcare system. This review identifies three main areas for further alignment with OECD standards and best practices in the field of health: 1. reorienting the healthcare system towards primary and preventive care in order to improve population outcomes and reduce the need for more costly care; 2. improving health outcomes and experiences of care by developing quality management systems; and 3. improving efficiency and sustainability to expand access and strengthen financial protection.
First, Bulgaria needs to intensify efforts to reorient the healthcare system towards primary and preventive care in order to improve population outcomes and reduce the need for more costly care. To reduce the over-reliance on hospitals and acute episodic care, Bulgaria should intensify efforts to put primary and preventive care at the centre of the health system. Bulgaria’s healthcare system relies heavily on hospital services. Bulgaria has 8.2 hospital beds per 1 000 population, almost double the OECD average of 4.3. Hospital discharge rates were 325 per 1 000 population in 2022, almost three times higher than the OECD average (129 per 1 000). While hospitals constituted 37% of health spending in 2022, ambulatory care providers accounted for only 15%. The referral system is inadequate, with many patients reaching out to emergency and hospital care for medical needs that could be dealt with at primary care level. Bulgaria should intensify its efforts to strengthen primary care by improving the referral system and defining clearer criteria and standards of care, as well as improving roles and responsibilities of general practitioners encouraging diagnosis, management and treatment of conditions that can be managed in primary care services. Nurses and community care workers (Health Mediators) should 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.
Second, to improve health outcomes and care experiences towards a more people centred healthcare system, Bulgaria should invest in developing robust infrastructures for healthcare system performance assessment and quality management with enhanced 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. Bulgaria currently lacks robust quality management systems built on relevant and reliable indicators and monitoring mechanisms. The assessment of health system performance and quality of care relies heavily on process indicators such as vaccination rates or inputs such as number of healthcare professionals or hospital beds. Bulgaria should put significant efforts on further strengthening their data infrastructure to develop relevant indicators to assess quality of care, people‑centredness of healthcare and patient safety. Drawing from the OECD’s Renewed Framework of Health System Performance Assessment and leveraging the data from the NHIS, further efforts need to put on identifying relevant areas for the Bulgarian healthcare system performance assessment and develop an agreed set of indicators to monitor performance. These efforts should particularly focus on measuring quality of care, including patient experiences and outcomes, and patient safety. Participating in international efforts such as the 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.
Third, Bulgaria should continue improving efficiency and sustainability to expand access and strengthen financial protection. 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 both below 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. 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 healthcare and medical treatment, to all social groups, in a transparent and timely manner. This includes ensuring access to preventive care and medical treatment while reducing out-of-pocket payments, which currently account for one‑third (35%) of all health spending, with pharmaceuticals making the majority (69%).