This chapter provides an overview of Bulgaria’s health system, examining its performance, recent policy reforms, and opportunities to enhance efficiency, transparency, and data-driven policymaking. The first section analyses the health status and healthcare needs of people in Bulgaria, addressing both physical and mental health conditions. The second section explores the structure and governance of the health system, outlining key challenges and policy efforts aimed at strengthening primary and community healthcare and addressing corruption in the health sector. The third section examines the health data infrastructure and governance supporting healthcare delivery, highlighting challenges such as underuse of health data for research and public interest purposes.
OECD Reviews of Health Systems: Bulgaria 2026
Abstract
Bulgaria had a population of about 6.5 million in 2023. The share of population aged 65 and older was 23.5%, above the OECD average of 18.5% (OECD, 2025[1]). The working age population has declined by 8.5% since 2011, while the number of people aged above 65 increased by 26.2% (OECD, 2025[1]) Bulgaria became a member state of the European Union in 2007, which facilitated emigration, including that of the health professionals. The largest share of Bulgarians abroad lives in Germany, followed by Spain, the United Kingdom and Greece. Most emigrants (85%) are of working age, and around half of are aged between 15 and 34 years, with a broadly equal share between women and men. The Gross Domestic Product (GDP) per capita was USD PPP 38 754, compared to USD PPP 59 880 in the OECD average, in 2023 (OECD, 2026[2]). Bulgaria is in the southern part of Central and Eastern Europe, and bordered by Greece and Türkiye to the south, Serbia and North Macedonia to the west and Romania to the north.
Life expectancy in Bulgaria has steadily increased over the last two decades but gender gap is wide
Over the last two decades, life expectancy in Bulgaria has increased from 72.3 in 2003 to 75.8 in 2023 (Figure 2.1). Major differences exist between genders, with women living to 79.7 years of age and men living to 72. The COVID‑19 pandemic had a major impact on life expectancy, which fell by 3.7 years between 2019 and 2021 (0.9 years on average in OECD countries in the same time period). By 2023, life expectancy had recovered the losses and reached an all-time high. Despite this, life expectancy remains below the OECD average (81.1) and the five OECD countries with comparable income level in the same region (79) (Czechia, Hungary, Poland, the Slovak Republic, and Slovenia, referred to as “neighbouring EU5” hereafter).
Note: Data refer to 2023 or the nearest year available.
Source: OECD Health Statistics 2025.
Bulgaria’s population has been declining and is expected to continue declining
A demographic crisis, fuelled by negative population growth and migration, has led to a population decline and a drop in the working-age population. The Bulgarian population has been declining for the last three decades and fell by 12.8% to around 6.5 million inhabitants in 2023 (OECD, 2025[1]). Population size is projected to continue declining, reaching 6.1 million by 2040 (OECD, 2025[3]) and to shrink by one‑fifth from by 2054, representing the largest negative growth in population size in the world among countries with at least half a million people (United Nations, 2024[4]) . Fertility rate in Bulgaria fell to 1.81 in 2023 for the first time, though it remains the third highest in the EU after France and Romania (Eurostat, 2025[5]). Bulgaria became a member state of the EU in 2007, which facilitated emigration, including that of the health professionals. Most emigrants (85%) are of working age, around half are aged between 15 and 34 years, with a broadly equal share between women and men (Molnar, Abendschein and Zhelyazkova, 2023[6]).
The population is also ageing. In 2012, almost one in four of people (19%) were aged 65 and over, with this figure increasing to 24% in 2023 (OECD, 2025[1]). Projections indicate that this trend will continue, reaching 26.5% by 2040 (OECD, 2025[3]). Like many OECD countries, Bulgaria should adapt the healthcare system to the needs of its ageing population, addressing increased burden of chronic diseases and demand for primary and long-term care (LTC), as well as its potential impact on the financial stability of the social health insurance (SHI) system.
A quarter of Bulgarians live in rural areas where the country faces a significant shortage of healthcare professionals
In 2023, around one in four Bulgarians (27%) were living in rural areas, where access to healthcare and basic needs are more limited than in urban areas (World Bank Databank, 2024[7]). Population ageing is more pronounced in villages (26%) than cities (20%), with a higher relative proportion of people aged 65 and older (Ministry of Health, 2022[8]). Related to this, mortality rates are also higher in the villages with 28 per 1000 people compared to 19 in the cities. The birth rate is slightly lower in villages compared to cities, with 8 and 9 births per 1 000 people, respectively. Mortality among children in villages (9 deaths per 1 000 live births) is higher than cities (5 deaths) reflecting issues with access to healthcare.
Shortages of healthcare professionals, including general practitioners, nurses and other specialists, are prominent across regions, and are exacerbated in rural and remote areas. Recognising these challenges, Bulgaria has developed strategies to attract medical students and healthcare professionals in rural areas (See Chapter 4).
Bulgaria has successfully reduced maternal and infant mortality over the past decade
Maternal deaths during pregnancy or childbirth declined over the past decade, decreasing from 7.9 deaths per 100 000 live births in 2010 to 6.8 in 2020. However, maternal mortality subsequently increased, reaching 12.4 in 2022 and 8.7 in 2023, levels above those observed a decade earlier. Over the 3‑year period 2021‑2023, maternal mortality in Bulgaria (8.73 deaths per 100 000 live births) was below the OECD average (10.3) but remained higher than the EU5 average (6.8) (Figure 2.2).
Infant mortality has decreased from 9.4 deaths per 1000 live births in 2010 to 5.1 deaths in 2020. According to national statistics, as of 2024, infant mortality has decreased further to 4.5 deaths per 1000, which constitutes a more than 50% decline compared to 2010 (Bulgarian National Statistical Institute, 2025[9]). While this is encouraging, in the 3‑year period 2021-2023, infant mortality in Bulgaria (5.1) still lies slightly above the OECD (4 deaths) and neighbouring EU5 (3.3 deaths) averages (Figure 2.2).
The main causes of death in children under one year in 2021 were perinatal conditions (228 deaths per 100 000 live births), congenital anomalies (developmental defects), deformations, and chromosomal aberrations (101 deaths) (Ministry of Health, 2022[8]). To address these issues, Bulgaria expanded the number of screening tests covered in the neonatal package and promoted seamless access to general practitioners, obstetricians, and paediatricians. Bulgaria has also recently implemented 12 integrated healthcare settings “the Centre for Comprehensive Services for Children with Disabilities and Chronic Diseases” to provide integrated care services to children with disabilities and chronic conditions (See Chapter 3).
1. Latest data from 2020‑2022 data. 2. Latest data from 2019-2021 data. 3. Latest data from 2018-2020 data.
Source: OECD Health Statistics 2025.
Cardiovascular diseases and cancer are responsible for nearly three‑quarters of all deaths
Cardiovascular diseases (CVD) – including ischaemic heart diseases and stroke – were the leading cause of mortality in 2023, which represented 62% of all deaths (OECD/European Observatory on Health Systems and Policies, 2025[10]). Cancer was the second leading cause of death, accounting for 17% of all deaths. Lung and colorectal cancer were the most frequent causes of mortality among cancer types.
Mortality rates due to heart attack and other ischaemic diseases were higher than in most OECD countries but are slightly lower than the EU5 average. In 2023, mortality rate from ischaemic heart diseases in Bulgaria was 166 deaths, below the EU5 average of 191, but above the OECD average of 112 (Figure 2.3). In addition, this figure has increased from 162 in 2013 to 166 in 2023, while in most OECD countries it has been decreasing over the past decade. Mortality due to stroke is higher than all OECD countries, signalling potential issues in acute care provision. Mortality rate from cerebrovascular diseases was 244 deaths in 2023, much higher from the EU5 average of 71 and the OECD average of 54 (Figure 2.3). While it has decreased from 263 in 2013 to 244 in 2023, it remained the highest rate compared to the mortality rates in OECD countries.
Other health concerns include tuberculosis (decreasing incidence over the last decade) and hepatitis B and C (higher prevalence over the past years) (see Chapter 3). The National Health Strategy 2030 prioritises investment in prevention and promotion activities through promoting a healthy lifestyle, developing a supportive environment and effective screening and prevention of chronic conditions (see Chapter 2). Recent reforms address access to CVD medicines by reducing out of pocket (OOP) payments and acute care provision through new centres for interventional diagnostics and endovascular treatment of cerebrovascular diseases, through financing from the NRRP.
1. 2022 data. 2. 2021 data.
Source: OECD Health Statistics 2025, based on the WHO Mortality Database.
Regional differences in mortality rates highlight uneven distribution of healthcare provision
There are significant differences in mortality between regions. In 2024, the mortality rates in Vidin, Montana and Kyustendil (24.5, 21.6 and 21 deaths per 1 000, respectively) were nearly double that of Sofia City (11.2 deaths) (Figure 2.4). Out of 28 regions, 21 regions had mortality rates above the national average (15.7 deaths). NRRP aims to address regional inequalities by recruiting and retaining healthcare professionals in rural and remote areas, modernising hospital infrastructure across the country and opening new centres for interventional diagnostics and endovascular treatment of cerebrovascular diseases (See Chapters 3 and 4).
Note: Data refer to 2024.
Source: National Statistical Institute, Bulgaria.
High avoidable mortality and associated risk factors call for stronger primary and preventive care and public health policies
Bulgaria has one of the highest rates of avoidable mortality compared to OECD countries, signalling major challenges in public health policies and health system performance, shortcomings in prevention and promotion programmes, and insufficient financial and policy resources to improve diagnosis and treatment. According to 2023 data, avoidable mortality ranks above most OECD countries, with 389 deaths per 100 000 population compared to the OECD average of 246 deaths. Mortality from preventable causes, which can be avoided through effective public health and prevention strategies, was 228 deaths per 100 000 population, above the OECD average (145 deaths) and neighbouring EU5 average (179 deaths) (Figure 2.5). Similarly, mortality from treatable causes, which can be avoided through healthcare interventions, including screening, diagnosis, and treatment, was higher than almost all OECD countries, with 161 deaths per 100 000 population (compared to 77 for OECD and 105 for neighbouring EU5) (Figure 2.5). According to the 2022 Eurostat data, mortality from preventable causes increased between 2019 and 2022, driven largely by COVID‑19‑related deaths (OECD/European Observatory on Health Systems and Policies, 2025[10]). By contrast, mortality from treatable causes was less affected by the pandemic but has shown little improvement over the past decade, calling for further actions on improving effectiveness and timeliness of healthcare delivery and preventive care.
1. 2022 data. 2. 2021 data. 3. 2020 data.
Source: OECD Health Statistics 2025.
Around a third of deaths are attributable to risk factors
Estimates from the Institute for Health Metrics and Evaluation (IHME) indicate that in 2021, more than one‑third of all mortality (36%) could be attributed to behavioural or environmental risk factors (OECD/European Observatory on Health Systems and Policies, 2025[10]). Dietary risks accounted for 19% of all deaths, above the OECD average (12%), reflecting poor dietary habits. The number of adults consuming at least five portions of fruit and vegetables a day is lower than almost all OECD countries with 5% in 2019 (OECD/European Observatory on Health Systems and Policies, 2023[11]; OECD, 2023[12]). Similarly, only one in ten adults (11%) exercised regularly. In terms of obesity, 12% of adults reported being obese in 2022. Almost one in four 15‑year‑olds (24%) reported being overweight or obese, higher than in OECD countries. The amendment to the Food Act prohibits the advertisement and marketing of genetically modified and “unhealthy” foods to children – including via television, print, and online. Food labelling follows standard EU labelling of putting ingredients on display. In recent years, the limitation or removal of specific food or beverage categories (unhealthy foods) has been a successful policy initiative for ensuring healthy, safe, and quality foods are offered. This policy applies to school canteens, retail outlets and organised events on the grounds of schools and childcare facilities (World Cancer Research Fund International, 2023[13]). Bulgaria should intensify its efforts to implement policies on nutrition advice and counselling in healthcare settings as well as on nutrition education on curricula. In addition, Bulgaria should use financial incentives to increase the availability and affordability of healthy food and create a healthy retail and food production environment along with food systems policies. Simplified front-of-pack food labelling (such as Nutri score) can improve people’s understanding of the nutritional content and increase healthier food choices in the population, with economic return on investment (OECD, 2022[14]). Annually, the Ministry of Health, in partnership with the National Centre of Public Health and Analyses, the Ministry of Education and Science, the Ministry of Culture, the Ministry of Youth and Sports, the Ministry of Environment and Water, the WHO Office for Bulgaria and the Bulgarian Red Cross, organises a National Student Competition “Ambassadors of Health”. The competition is held in support of a healthy lifestyle for young people (grades 1‑12), with the aim of preventing behavioural health risk factors related to unhealthy eating, low physical activity, alcohol abuse, and smoking. Every year the Ministry of Youth and Sports finances the organisation of School Games for students from the 5th to the 12th grade and school games for students with physical and mental disabilities (OECD/European Commission, 2025[15]). In 2024, a new pilot programme “Sports Hour” was launched to ensure participation in physical exercises, mobile games and sports activities for children, to form and develop school and student sports teams. Around 92 000 students participated to the pilot programme.
Tobacco smoking was responsible for 8% of all deaths in 2021, similar to the OECD average. At 29%, smoking rates in Bulgaria are higher than all OECD countries (15%) (Figure 2.6). Moreover, the share of people aged 15 and over who smoke daily has remained unchanged between 2008 and 2019. The differences between men and women are considerable, with men smoking almost twice as much as women. The complete ban on smoking in all closed public places and in some open public places was introduced in 2012 and advertising of tobacco is prohibited. Bulgaria has added health warnings on smoking packages in accordance with the EU and national legislation. However, the country does not require plain packaging for tobacco products and scores poorly in cigarette price, trend in cigarette affordability, and tax structure (Antonov and Velichkov, 2023[16]; Chaloupka and Tauras, 2022[17]). Tobacco taxes in Bulgaria are levied in accordance with the EU tobacco tax directives. In 2025, the European Commission’s updated minimum excise duties for tobacco. Further national-level increases in excise taxes on tobacco products are expected to push up the price of tobacco products by almost five times by 2029 in Bulgaria, which already had two increases in January and May 2025. Bulgaria has an advanced tobacco production capacity (~15 billion cigarettes per year), which also feeds back into the high smoking rates. Further efforts should focus on introducing plain packaging with text/graphic warning label, increasing awareness among the population, and increasing taxes (as cigarettes remain affordable).
Note: Data refer to 2023 or nearest year. 1. Most recent data point corresponds to 2019.
Source: OECD Health Statistics 2025.
Alcohol use was responsible for 4% of all deaths, on par with the OECD average. In 2022, Bulgarian adults consumed 11.2 litres (equivalent of pure alcohol) per capita on average, close to countries in the same region, such as Czechia (11.2), Hungary (10.3) and Poland (10), but above the OECD average (8.5 litres) (Figure 2.7). Alcohol consumption has risen, increasing by 1 litre per capita between 2010 and 2022. Consumption only dropped in 2020, likely a result of pandemic-related restrictions, and no more recent data is available to confirm a rebound effect. The proportion of the population reporting heavy episodic drinking (defined as drinking more than six standard drinks within a session) at least once a week was 1.7% in 2019, though the difference between men and women was significant (2.9 and. 0.7, respectively) (Eurostat, 2024[18]). Bulgaria applies excise taxes on alcohol in line with the tax structures, rates and product definitions required by the EU alcohol tax directives. According to the ten policy areas within WHO’s Global Strategy to Reduce the Harmful Use of Alcohol, recent interventions address availability, marketing, pricing, reducing harm as well as leadership and reducing public health impact (OECD, 2021[19]). Bulgaria should increase its efforts on implementing interventions in the community and in the healthcare settings, as well as practices on “drinking and driving” and “monitoring and surveillance”.
Note: Data refer to 2023 or nearest year.
Source: OECD Health Statistics 2025.
Although Bulgaria earmarks 1% of excise duties on tobacco and alcohol products to fund national primary prevention programmes, resources for public health interventions are insufficient. Specific taxes present a challenge with taxes not maintaining their real value over time, particularly in times of high inflation (World Bank, 2024[20]). Moreover, good economy and income growth make tobacco and alcohol more affordable. Access to, and enforcement of, existing health promotive and preventive services and strategies face several challenges. Tobacco control measures, such as bans on public smoking and on cigarette sales to minors as well as guidelines for tobacco advertising and packaging, are characterised by limited institutional capacity to deliver information campaigns. Additionally, the effectiveness of national programmes to promote healthy lifestyles and tackle chronic conditions is not proven. Despite mixed evidence of their impact, the Healthy Kids Project and the National Strategy for Physical Education and Sports Development 2012‑2022, which were established to address the increasing numbers of overweight and obese children, have been renewed. The National Programme for the Prevention of Chronic Non-Communicable Diseases 2021‑2025 aims to intensify national efforts on addressing smoking, healthy eating patterns, physical activity, and alcohol intake.
Mental health diseases are one of the leading causes of disability
Mental health diseases were the second leading cause of years lived with disability in 2021, though the prevalence of mental health disorders was lower than the OECD average (14 200 cases vs. 16 099 per 100 000 population) (IHME, 2025[21]). Self-reported depressive symptoms are also low: 5% of people reported currently having depressive symptoms in 2019 compared to the OECD average of 7%. This is more prevalent in women (5%) than in men (3%). In 2020, almost half of employees reported having been exposed to risk factors that may impact their mental health, slightly lower than the OECD average (Figure 2.8). Suicide rates have been on a downward trend, decreasing by 25% between 2011 and 2021. There is a significant difference between men and women, with suicide rates being almost 5‑fold higher in men (Eurostat, 2024[22]).
Note: Data refer to 2020.
Source: Eurostat (2025).
Nearly 13% of people reported living with a mental health disorder in 2019 (OECD/European Observatory on Health Systems and Policies, 2023[11]). Almost half (46%) were not able to seek care because it was too expensive. Around 31% indicated that they did not seek care because they were afraid of doctors or treatment, which is above the OECD average of 20%. Over 80% of people agreed that patients with mental health conditions were judged differently by society than other patients. Furthermore, almost half of them (47%) indicated that medical professionals also judged patients with mental health conditions differently, the fourth highest among EU countries (Eurobarometer, 2023[23]). Mental health care in Bulgaria has been provided mainly in hospital settings, which are historically located outside the populated areas, and are not in accordance with the administrative division of the country. Patients are usually treated in these institutions, staying apart from their families and communities and disrupting their social lives. Bulgaria has increased its efforts to develop and organise residential and out-patient psychiatric care in the community, including equipping them with multiprofessional practices (See Chapter 3).
Healthcare system is based on social health insurance
Various laws and bylaws govern the Bulgarian healthcare system, including the structure, financing, and monitoring of the system, as well as the structural and operational requirements of medical facilities. The 2005 Health Act regulates the public relations directed to preserve population health, while the establishment, organisation and operation of medical institutions is regulated by the 1999 Medical Establishments Act. Finally, the 1998 Health Insurance Act governs health insurance and associated public relations.
As per the Health Insurance Act, health insurance is of two types – mandatory and voluntary (the latter having a minimal role). Every citizen is obliged to pay a monthly health contribution, and the collection of the funds from the mandatory health insurance contributions is carried out by the National Revenue Agency. The state covers contributions for pensioners, children and students, and unemployed individuals who are entitled to compensation. The public benefits package includes primary and specialised outpatient medical care, laboratory services, hospital diagnostics and treatment, and highly specialised medical services for oncological, cardiovascular, or orthopaedic diseases requiring long term treatment, including rehabilitation. Emergency care, inpatient mental health care, in vitro fertilisation, and public health services are fully covered by the state budget, or other dedicated funds, and the government expanded the preventive benefits package and the package of obstetric care and medical diagnostics for uninsured women in 2022. The benefits package is regulated by an ordinance of the Minister of Health, which is updated annually.
User fees apply for most services and are defined as a fixed fee for service. Additionally, copayments for medicines are prevalent. The mandatory health insurance contribution is 8% of personal income (shared between the employee and the employer) and the user fee for covered persons is EUR 1.5 regardless of the value of the services used. The hospital treatment fee is approximately EUR 0.51 per day and paid regardless of the length of the hospital stay, but for no more than 10 days per year. Certain population groups are exempted from user fees when availing medical aid from the National Health Insurance Fund (NHIF) package, thereby ensuring access to healthcare services for vulnerable groups of the society. These are children up to the age of 18, and if they continue their education – up to the age of 26, pregnant women and women in labour up to 45 days after giving birth, patients with malignant neoplasms, and health-insured persons with over 71% reduced working capacity. In addition, the state budget also provides funds for diagnosis and treatment in hospitals for people who cannot afford to participate in health insurance because they have no income or property. Private health insurance (PHI) is carried out on the basis of a medical insurance contract where type, prices, conditions and procedures are determined by the contracts between healthcare providers and insurers. In Bulgaria, PHI plays a minimal role.
The SHI is based on a single‑payer system, in Bulgaria’s case the NHIF. NHIF is the only health insurance fund in the country that purchases health activities within the scope of health insurance. The NHIF comprises a central administration, district health insurance funds in all regions of the country and divisions of the district health insurance funds. The NHIF is governed by a Governor and a Supervisory Board of Directors, consisting of representatives of patients’ rights organisations, workers and employees, employers and the state, one of whom is the Executive Director of the National Revenue Agency. The package of health activities guaranteed by the NHIF budget contains medical activities, services and goods defined by type and scope, by individual medical specialties, by diseases or groups of diseases.
Healthcare providers are autonomous and self-governing. NHIF negotiates prices and volumes with providers based on the previously agreed health package between NHIF and the medical, dental, and pharmaceutical unions. Ambulatory care – such as primary and dental care, specialised outpatient care, some hospital services, and pharmaceuticals – is delivered primarily by the private sector, while emergency care centres, transfusion centres, psychiatric hospitals, university hospitals, and centres for children with disabilities and chronic conditions are exclusively state‑owned. On the other hand, responsibility of district hospitals is split between the state and the municipalities, the latter also managing various specialised outpatient providers and multi-profile and specialised hospitals.
The social health insurance system offers covers about 94% of the population and provides access to a broad benefits basket, albeit out of pocket payments represent more than one‑third of health spending
The share of uninsured people – defined as the share of a population covered for a core set of healthcare services – is estimated at 6% in 2023, above most OECD countries and three times higher than the OECD average (2%) (Figure 2.9). 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). This includes citizens living abroad, long-term unemployed people and individuals who choose not to pay into the SHI system. Those without a valid identity card, including the Roma population, homeless people and undocumented migrants, face particular challenges, as this is a requirement for SHI registration. Furthermore, though the statutory benefits package covers a range of primary, secondary and tertiary level healthcare services and goods, user fees are common, driving OOP spending (OECD/European Observatory on Health Systems and Policies, 2023[11]). A recent study, examining household expenses and financial burden which draw upon a sociological survey and cost data from the NHIF and the National Health Information System (NHIS), showed that one in two parents struggles to afford their child’s medications, with 14.4% facing severe financial hardship (European Observatory on Health Systems and Policies, 2024[24]).
Note: Data refer to 2023 or the nearest year. Data refers to the share of a population covered for a core set of health services, offering an initial measure of access to care and financial protection.
Source: OECD Health Statistics 2025.
User fees and cost-sharing apply for most services and goods in the basic benefits package, including dental care, outpatient visits, laboratory tests and hospital stays. These user charges as well as direct payments for services outside the benefits package and by the uninsured contribute to the high OOP spending in Bulgaria. Some services, including occupational healthcare, elective cosmetic surgery, elective termination of pregnancy and contraception, are not covered. There is limited coverage of outpatient medicines, medical products, dental care, long-term nursing care, and long-term rehabilitation. Others are fully covered by the state budget, including emergency care, inpatient mental health care, transfusion haematology, in vitro fertilisation and transplantations, and public health services. As of 2024, the benefits package was expanded to include laboratory tests for preventive purposes. In addition, more than 400 medicines for CVDs grouped into 52 International Non-proprietary Names (INN) groups are fully reimbursed, in line with the NHIF’s long-term strategy to make treatment for major chronic conditions more affordable. The 2025 budget of the NHIF also introduces full reimbursement for antibiotics and antiviral drugs prescribed to children under seven, effective from 1 July 2025 (Republic of Bulgaria, 2025[25]). The National Strategy for People with Disabilities 2021‑2030 and the National Strategy for Roma Integration 2020 attempts to address access gaps among vulnerable groups.
The governance of the healthcare system is highly centralised
The key authorities are the National Assembly (via the Parliamentary Healthcare Committee), which approves budgets, adopts relevant health policies, and elects the governor and the deputy-governors of NHIF; the Ministry of Health, which oversees the governance; the Council of Ministers, which guides national health policy, and the NHIF (OECD/European Observatory on Health Systems and Policies, 2025[10]). The latter in turn operates via 28 Regional Health Insurance Funds (RHIF), which receive funding based on population information, historical allocations and health needs estimates and are responsible for purchasing of health services. The Ministry of Health is responsible for strategic planning in the healthcare system. At the district level, public health policy is organised and implemented by 28 Regional Health Inspectorates (RHIs), which are the local bodies of the Ministry of Health. The RHIs – born from the fusion of regional health centres with the then called Regional Inspections for Protection and Control of Public Health – perform activities on the state health control at district level, control and register healthcare providers; collect and analyse health information; co‑ordinate and implement national health programmes; monitor environmental and other factors and perform activities with importance for the population health; as well as laboratory analyses and tests. Municipalities own a considerable proportion of healthcare providers, most of which specialise in outpatient care, as well as multi-profile and some specialised hospitals. Apart from this, in practice, municipalities play a limited role in public health policy development. Reforms from 1990 onwards, including the establishment of regional structures of the Ministry of Health and the NHIF, aimed to decentralise and liberalise the system. However, governance remains relatively centralised, resting mostly with the Ministry of Health and Council of Ministers.
The Bulgaria 2030 National Development Programme, subdivided into three‑year implementation plans, is the strategic document of the highest order in the hierarchy of national programme documents. It sets out the objectives of the various development policies across all public sectors. Relevant to health is Priority 12, “Health and Sports”, which identifies the main areas of impact, including health promotion and disease prevention, optimising the healthcare network and improving the access and the quality of care at all levels, as well as human resources, upgrading the NHIS, and developing e‑health. The National Health Strategy, the main strategic document in the sector, is proposed by the Minister of Health, approved by the Council of Ministers, and finally adopted by the National Assembly. This strategy, as well as the associated national programmes and plans, is drafted based on the health needs of people, recent epidemiological and demographic trends, and the availability of national resources.
A significant proportion of the Recovery and Resilience Plan funding is to modernise the healthcare infrastructure
Despite the extensive reliance on hospital resources, efforts are needed to make adequate use of available resources and offer up-to-date services. In 2023, Bulgaria performed 12.5 laparoscopic appendectomies per 100 000 population, below the OECD average (98.5) and neighbouring EU5 average (75.7) (Figure 2.10). Laparoscopic cholecystectomies (81.6 per 100 000 population) were also below the OECD average of 174.4 and neighbouring EU5 average of 211.1. Similarly, repair of inguinal hernia (49.6 per 100 000 population) was also below the OECD and EU5 averages of 70.5 and 80.8, respectively. This signals difficulties towards implementing new technologies to perform modern surgeries. To address this, Bulgaria seeks to modernise its healthcare infrastructure through their NRRP, specifically Investment 1 “Modernisation of medical facilities for hospital care”. This includes Component 1 “Modernisation of the country’s paediatric care system”, Component 2 “Building capacity for the application of the most modern methods for the treatment of oncological diseases in Bulgaria through the establishment in the city of Sofia of a National centre for radiotherapy with proton therapy, with a focus on the treatment of children”, and Component 3 “Modernisation of the system for diagnosis and treatment of oncological diseases in the country”.
Note: Data refer to 2023 or nearest year.
Source: OECD Health Statistics 2025.
Bulgaria has a high number of hospital beds and discharge rates. Though this points to a strongly hospital-centric system, these figures are not accompanied by significantly high hospital spending (see Chapter 4). In 2023, Bulgaria had 8.6 hospital beds per 1 000 population, higher than the neighbouring EU5 average of 5.8 beds and the OECD average of 4.2 beds (Figure 2.11). This number has been consistently increasing over the last decade, from 6.6 in 2012 to 8.6 in 2023, while decreasing in most OECD countries. Hospital discharge rates, following a pandemic-related decline, sat at 322 per 1 000 population in 2023, almost three‑fold higher the OECD average (128 per 1 000) and more than twice the neighbouring EU5 average (147 per 1 000).
Note: Data refer to 2023 or nearest year.
Source: Health Statistics 2025.
Note: Data are discharges for curative (acute) care unless stated. 1. Data includes total discharges for inpatient care. 2. Data excludes discharges of healthy babies. 3. Data excludes discharges from certain facility types. 4. Latest data from 2021-2022.
Source: OECD Health Statistics 2025.
While legislation guarantees the formal participation of patients in health policymaking, their involvement is hampered by a lack of clear roles
As per the Law on Normative Acts, people and non-governmental and non-profit associations may participate in public consultations on draft normative acts. Representatives of patients’ rights organisations have participated in the NHIF’s Supervisory Board, which participates in negotiation processes, as well as in a number of advisory bodies to the Ministry of Health, such as the National Mental Health Council, the National Commission for the Preparation of a National Health Map, the Advisory Council to the Minister of Health, and the National Council for the Integration of People with Disabilities, and the Public Council on Patient Rights. The latter was established to monitor and analyse activities related to the rights of the patients, such as the implementation of the regulatory framework in the field of patients’ rights, as well as to provide consultations on the drafts of normative acts.
While legislation and bylaws oblige institutions to have patient representatives which guarantee their formal participation, there are issues with how these translate in practice. Patient voice is usually limited, the role of patient representatives is not defined, decision making capacity or partnering with patients is also not practiced by institutions. In addition to patient participation to health policies and decisions, individual patient voice is also not systematically measured and used to assess the performance of healthcare systems (see Chapter 3). Bulgaria should make significant efforts on enhancing patient participation in various areas. Engaging patients in design, development, implementation as well as communication and dissemination of programmes is crucial to raise awareness, fight against misinformation and disinformation, and make healthcare systems more centred around people’s needs. In addition, Bulgaria can significantly benefit from measuring patient-reported outcome and experience measures (PROMs and PREMs) to assess to what extent healthcare deliver from patient perspective.
Bulgaria has taken steps to address corruption and informal payments in the healthcare system, further efforts should focus on monitoring and checks, enhancing transparency and public engagement
Bulgaria has historically had problems of corruption and informal payments. While broader concerns about corruption persist, specific challenges manifest in the healthcare system, notably regarding informal payments and systematic inefficiencies linked to issues of transparency and resource management. The 2024 Special Eurobarometer on Corruption shows that 85% of respondents consider corruption widespread in Bulgaria (compared to an EU average of 68%), and 32% of respondents feel personally affected by corruption in their daily lives (compared to an EU average 27%) (Eurobarometer, 2024[26]). While broader concerns about corruption persist, specific challenges manifest in the healthcare system. Compared to 2023, the proportion of people who think corruption is widespread in the healthcare system have increased by 4 percentage points (p.p.) to 49% compared to an EU average of 27%. In 2023, 6% of people reported having to give an extra payment or a valuable gift to a nurse or a doctor or having to donate to the hospital (not including official fees) when visiting a healthcare setting, a drop of 4 p.p. compared to 2019, but remaining slightly above the EU average (4%) (Eurobarometer, 2023[27]). In recent years, informal payments have been formalised in the healthcare system through various mechanisms. For example, informal payments usually are made in order to enhance access and quality such as the choice of clinician/team and consumables for a preferential treatment (such as getting another implant type), which is not reimbursed by the NHIF but considered to be a higher quality, as reported by patient organisations. In certain contexts, patients also reported making unofficial payments to access documentation related to complaints they had submitted following an unsatisfactory experience with the healthcare system.
In recent years, Bulgaria has taken steps to strengthen the prevention of corruption and improve its anti-corruption and integrity system. The National Strategy for Preventing and Combatting Corruption (2021-2027) outlines the priorities of the state policy for preventing and countering corruption, including in the healthcare system, emphasising the need for effective mechanisms for enhanced control, publicity, and accountability of the spending of resources of medical institutions. In October 2023, Bulgaria adopted a new Anti-Corruption Act (ACA), which includes measures to counter acts of corruption by public office holders, regulations on managing conflicts of interest and their verification procedure. Amongst others, the Act applies to the leadership of the NHIF and regional health insurance funds, public hospitals and health inspectorates. With the adoption of this Act, Bulgaria restructured its anti-corruption authority by dividing the former agency, the Commission for Anti-Corruption and Illegal Asset Forfeiture (CACIAF), into two specialised entities: the Commission for Anti-Corruption (CAC) and the Commission for Illegal Asset Forfeiture (CIAF) (OECD, 2025[28]). In 2019 the institution of the Ombudsman of the Republic of Bulgaria was accredited by the United Nations, in accordance with the Paris Principles, as a National Human Rights Institution. The National Assembly elects an Ombudsman who advocates for the rights and freedoms of citizen. The activities of the Ombudsman are regulated by the Law for the Ombudsman. Within the rights of this position, the ombudsman can report to every administrative structure in the country and can make proposals in front of the respective administration (Ombudsman of the Republic of Bulgaria, n.d.[29]). The newly developed NHIS supports checking irregular patterns. As of 1 June 2025, the NHIS will carry out real-time controls for prescribed and dispensed medicines reimbursed by the NHIF. The new rules will enable the NHIF to carry out preventive control before payment, also to increase the efficiency of the spending of the public resources of the NHIF. Through the eHealth app (eZdrave), citizens can also contribute to the transparency and control. Users receive notifications related to the issuance of a new electronic health document or the correction of an existing one and can notify the Ministry of Health of any irregularities. In the past years, there were a few cases of complaints filed, on which checks have been carried out and sanctions imposed.
In addition to these measures, Bulgaria should further strengthen its efforts to tackle corruption in the health sector by enhancing monitoring and checks, transparency, and public engagement. The NHIS should reinforce checking patterns in service provision and referrals to identify and address any irregularities. The data collected via the NHIS could also be used to improve the identification, assessment and management of corruption and integrity risks in the healthcare sector, feeding into the risk management strategies and risk registers which public organisations are required to establish under the Financial Management and Control in the Public Sector Act (FMCPSA). Promoting patients’ access to and awareness of the information about what services cost, what is reimbursed, and what is covered is important to enhance transparency. This way patients can further contribute to checks by monitoring their own health records, prescription and treatment history, as well as the cost and reimbursement of each activity, through the NHIS. Given the current low participation in the eHealth app (eZdrave), Bulgaria should step up its efforts to expand the coverage of electronic health records across the entire population. Audit trails can also track who accessed or changed a patient’s file, discouraging misconduct.
Bulgaria should further invest in nurturing integrity in its healthcare sector and enhance trust by engaging patients, healthcare professionals, and other stakeholders. Easily accessible and understandable patient rights and service entitlements can reduce informal payments by increasing awareness and reducing the ambiguity that fosters informal payments. Establishing more formalised, safe, confidential, and reliable complaints and patient safety systems with a central register in all healthcare settings is essential to monitor potential activities. Similarly, establishing systems for compliment letters to healthcare professionals and structures can also have a transformative approach in increasing job satisfaction. Improving the working conditions of healthcare professionals will be important to reduce the temptation to accept bribes and informal payments.
Overall, building on ongoing efforts under in the National Strategy for Preventing and Combatting Corruption, Bulgaria could benefit from developing a comprehensive sectorial strategy to address corruption and promote integrity in the health sector. In line with the criteria identified by the OECD Public Integrity Indicators, such a strategy would ideally, identify specific integrity risks and challenges in the sector, establish priorities and objectives, define specific actions for achieving desired outcomes, set institutional responsibilities and build consensus around objectives and activities, and facilitate effective implementation through monitoring and evaluation processes based on indicators for measuring (OECD, 2025[30]).
Significant progress has been made in developing the national health information system, but further efforts are needed to enhance data use for policymaking and secondary purposes
Bulgaria has been strengthening its health information infrastructure with the digitalisation of the healthcare system. The NHIS collects, processes, and stores all health-related information including electronic medical records. A unified environment for the exchange of medical data (the core of the system) integrates multiple existing data platforms, such as the medical software, the data from the NHIF, the National Council on Prices and Reimbursement of Medicinal Products (NCPRMP) and other key healthcare institutions. The NHIS was created with national funding and endorsed by the 2020 National Health Strategy. The NRRP supports its implementation through the development of a platform for medical diagnostics (See Chapter 4). The features include e‑referral, e‑prescription, electronic medical record, registers for vaccinations, mobile app for healthcare professionals and integration of hospital and emergency services. All healthcare centres have been integrated into the NHIS, including almost 400 hospitals, 30 000 specialists, laboratories, and dental care services. It is used by over 19 000 healthcare professionals and over 3 600 pharmacies and over 4 300 pharmacists across the country. On 30 April 2025, over 520 million electronic health documents such as e‑prescriptions, e‑examinations, e‑referrals and laboratory results have been registered (Ministry of Health, 2025[31]).
In order to achieve interoperability of information systems in healthcare, national nomenclatures have been developed and introduced, which are mandatory for use in the healthcare sector in relation to medical information and its exchange in real time. In addition to nomenclatures, health information standards have also been introduced. The software architecture of the “common platform for the exchange of medical data - ESOMED” is built through SOA (web-services-oriented architecture) with opportunities for co‑operation and interaction of all NHIS modules/systems/subsystems and various applications used by medical and health facilities, including new participants defined by the relevant regulatory framework. Overall, the system is based on the latest EU standards for interoperability (such as HL7 FIHR). Further integrations with other existing systems such as NHIF, the Bulgarian Drug Agency, and the National Council on Prices and Reimbursement of Medicinal Products has recently been achieved. Foreseen linkages with other systems include integration with the Ministry of Education and Science, Ministry of Transport and Communications and with the Ministry of Interior for driver’s licenses.
Although significant developments regarding the features and its implementation in the healthcare system, data access and use are limited. Adoption on the patient side has been slower: the portal eZdrave, accessible through web and mobile app, has 130 000 active users, or 2% of the Bulgarian population. Authentication is based on an eSignature that must be obtained by the user, which has been identified as an additional obstacle upon accessing electronic records. To address this, the Ministry of Health facilitated the obtention of the signature through the support of RHIs. However, this approach also has access difficulties for some population groups such as those travelling long distances to reach an RHI centre or those who have to take time off work to apply during working hours. In addition, although data are collected and stored in a central data repository, their use for decision making purposes is limited. Lack of frameworks to guide systematic data collection and use hampers its usefulness (see Chapter 3). Moreover, while secondary use of data is technically possible, the access to data and use by different stakeholders remain challenging due to time‑consuming administrative steps. The National Strategy for e‑Health and Digitalisation of the Health System -2030, approved in 2024, envisages the development and implementation by 2030 of additional modules and functionalities related to the secondary use of data, including for research and statistical purposes, as well as for cross-border data exchange in accordance with the adopted Regulation (EU) 2025/327 on the European Health Data Space.
Bulgaria is striving to reach international standards for data collection and use its data for cross-country learning. It contributes data to multiple international data collections, including the OECD Health Data Questionnaire, the OECD/Eurostat/WHO-Europe Joint Questionnaire on Non-Monetary Health Care Statistics, and the OECD/Eurostat/WHO Joint Health Accounts Questionnaire. In addition, Bulgaria has submitted data to the OECD Health Care Quality Indicators and Outcomes questionnaire for indicators on avoidable admissions and integrated care for the first time. This marks a positive development towards better understanding and monitoring of the healthcare system performance.
References
[16] Antonov, P. and V. Velichkov (2023), “Too little too late - a critical view of Bulgaria’s increased excise tax regime”, Tobacco Prevention & Cessation, Vol. 9/Supplement 2, https://doi.org/10.18332/tpc/172744.
[9] Bulgarian National Statistical Institute (2025), Crude death and infant mortality rates in 2024, https://www.nsi.bg/en/statistical-data/213/682.
[17] Chaloupka and Tauras (2022), Taxation of Emerging Tobacco Products: 2022 Update [Report]. Tobacconomics, https://www.tobacconomics.org/research/taxation-of-emerging-tobacco-products-2022-update/.
[26] Eurobarometer (2024), Citizens’ attitudes towards corruption in the EU in 2024.
[27] Eurobarometer (2023), Citizens’ attitudes towards corruption in the EU in 2023, https://europa.eu/eurobarometer/surveys/detail/2968.
[23] Eurobarometer (2023), Flash Eurobarometer 50: Mental health, https://europa.eu/eurobarometer/surveys/detail/3032.
[24] European Observatory on Health Systems and Policies (2024), Bulgaria, https://eurohealthobservatory.who.int/monitors/health-systems-monitor/countries-hspm/hspm/bulgaria-2018.
[5] Eurostat (2025), Fertility indicators, https://doi.org/10.2908/TPS00199.
[22] Eurostat (2024), Death due to suicide, by sex, https://doi.org/10.2908/TPS00122.
[18] Eurostat (2024), Frequency of heavy episodic drinking by sex, age and income quintile, https://doi.org/10.2908/HLTH_EHIS_AL3I.
[21] IHME (2025), Global Burden of Disease Study 2021 (GBD 2021) Results, Institute for Health Metrics and Evaluation.
[31] Ministry of Health (2025), National Health Information System, https://his.bg/en.
[8] Ministry of Health (2022), Annual Report on the State of Health of Citizens of the Republic of Bulgaria, 2021, https://www.mh.government.bg/bg/politiki/godishen-doklad-za-zdraveto.
[6] Molnar, M., M. Abendschein and Z. Zhelyazkova (2023), “Better jobs and incomes in Bulgaria”, OECD Economics Department Working Papers, No. 1759, OECD Publishing, Paris, https://doi.org/10.1787/38d07f99-en.
[2] OECD (2026), OECD Data Explorer: Annual GDP and consumption per capita, US $, current prices, current PPPs, https://data-explorer.oecd.org/.
[1] OECD (2025), OECD Data Explorer: Historical population data, https://data-explorer.oecd.org/.
[3] OECD (2025), OECD Data Explorer: Population projections, https://data-explorer.oecd.org/.
[30] OECD (2025), Quality of strategic framework, OECD, Paris, https://oecd-public-integrity-indicators.org/indicators/1000053.
[28] OECD (2025), Reforming Bulgaria’s Anti-corruption Authorities: Towards Effective Strategic Planning and Asset Recovery, OECD Public Governance Reviews, OECD Publishing, Paris, https://doi.org/10.1787/11ef33c9-en.
[12] OECD (2023), Health at a Glance 2023: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/7a7afb35-en.
[14] OECD (2022), Healthy Eating and Active Lifestyles: Best Practices in Public Health, OECD Publishing, Paris, https://doi.org/10.1787/40f65568-en.
[19] OECD (2021), Preventing Harmful Alcohol Use, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/6e4b4ffb-en.
[15] OECD/European Commission (2025), EU Country Cancer Profile: Bulgaria 2025, EU Country Cancer Profiles, OECD Publishing, Paris, https://doi.org/10.1787/c6533317-en.
[10] 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.
[11] OECD/European Observatory on Health Systems and Policies (2023), Bulgaria: Country Health Profile 2023, State of Health in the EU, OECD Publishing, Paris, https://doi.org/10.1787/8d90f882-en.
[29] Ombudsman of the Republic of Bulgaria (n.d.), 2025, https://www.ombudsman.bg/en/p/ombudsman-act-265.
[25] Republic of Bulgaria (2025), Law on the NHIF’s Budget for 2025, https://dv.parliament.bg/DVWeb/showMaterialDV.jsp?idMat=233618.
[4] United Nations (2024), The 2024 Revision of World Population Prospects, https://population.un.org/wpp/.
[20] World Bank (2024), Bulgaria’s Health Taxes - Overview, Trends and Simulation Results for Potential Optimization of Health Tax Levels, https://documents1.worldbank.org/curated/en/099011224101585952/pdf/P180223179c581081abe310a4406bc2a68.pdf.
[7] World Bank Databank (2024), Rural population (% of total population).
[13] World Cancer Research Fund International (2023), NOURISHING policy index: Bulgaria, https://www.wcrf.org/research-policy/library/nutrition-policy-status-in-bulgaria/.