This chapter examines key characteristics of Bulgaria’s health system and the policies supporting its sustainability and resilience. The first section focusses on system financing and financial sustainability, outlining challenges and recent efforts to enhance sustainability. The second section assesses the health workforce, addressing shortages and uneven distribution while outlining recent reforms aimed at improving retention. The third section reviews recent developments to combat communicable diseases, tackle antimicrobial resistance, and enhance the system’s preparedness for effective crisis response.
OECD Reviews of Health Systems: Bulgaria 2026
Abstract
Health spending per capita is lower than most OECD countries, with a significant proportion of out-of-pocket spending
Health expenditure in Bulgaria has grown modestly over the last decade, having spent 7.9% of its GDP in health in 2023, below the OECD average (9.3%) but similar to the neighbouring EU5 average (8.2%) (Figure 4.1). In terms of per capita spending, Bulgaria spent USD PPP 2 860 in 2023, lower than most OECD countries and half the OECD average of USD 5 961 (Figure 4.1).
Note: Data refer to 2024. Figures represent total values.
Source: OECD Health Statistics 2025.
In 2023, public sources accounted for 63% of current health expenditure, below the OECD average (75%) (Figure 4.2). Private health expenditure reached 37% of health spending, almost exclusively in the form of OOP spending (36%). Though one of the highest OOP spending levels when compared to OECD countries (OECD average: 19%), this figure has been decreasing from almost half of health spending a decade prior. OOP spending is a result of cost-sharing for most statutory services and direct payments for services and medicines. Pharmaceuticals accounted for more than two‑thirds of all OOP spending in 2023 (67.4%), with negative ramifications for access. Direct payments are incurred for services and goods not included in the basic package at prices set by individual providers, for services and goods that are included but outside the standard public patient pathway, and for uninsured individuals.
Note: Data refer to 2023. Category “Other” refers to financing by NGOs, employers, non-resident schemes and unknown schemes. 1. All spending by private health insurance companies reported under compulsory health insurance. 2. Latest available data from 2022.
Source: OECD Health Statistics 2025.
In 2022, 12% of government spending in Bulgaria was dedicated to health, standing below the OECD average of 16% and slightly below neighbouring EU5 average of 13%. This figure has modestly increased in the last two decades. While this implies there may be a need for greater prioritisation of health in the public budget, the narrow margin compared to other countries and the various inefficiencies discussed in this report suggests that the primary focus should be on ensuring greater value for public spending, allowing coverage to be expanded and OOP spending to be reduced. Ensuring sufficient fiscal space is crucial towards a sustainable health system, especially in the context of an ageing population and the rise in prevalence of non-communicable diseases.
Financing of inpatient and outpatient care is mostly public, while pharmaceuticals are mostly paid through private sources of funding
As discussed, public coverage of health spending is a crucial part of the healthcare landscape. Public financing varies widely across healthcare services. In Bulgaria, while inpatient care was financed almost exclusively through public sources (92%), outpatient medical care, pharmaceuticals, and therapeutic appliances lagged behind the OECD average in 2023 (Figure 4.3). This was especially the case of pharmaceuticals, where less than one fourth is public financing (23%), less than half the OECD average (57%). However, almost half of dental care (44%) was financed publicly, above the OECD average of 34%. OOP spending constituted 77% of spending on pharmaceuticals, in fact spending on pharmaceuticals made up most of OOP spending in Bulgaria (69%). This has deep implications for adequate access to care as well as efficiency. Though steps have been taken to expand coverage of essential medicines, more can be done to ensure value, including incentivising the use of generics whenever possible.
Note: Data refer to 2023. Outpatient medical services mainly refer to services provided by generalists and specialists in the outpatient sector. Pharmaceuticals include prescribed and over-the‑counter medicines as well as medical non-durables. Therapeutic appliances refer to vision products, hearing aids, wheelchairs and other medical devices.
Source: OECD Health Statistics 2025.
Private health insurance has a small role; efficiency and equity should be carefully considered should the role of private health insurance develop further
Regulated by the Health Insurance Act, private health insurance is supplementary, with people paying premiums for faster access to and better quality of healthcare services. The type of services, prices, and conditions for insurance are defined by prior agreements between insurance companies and providers. In 2022, only 0.7% of total health spending was attributed to PHI schemes, in contrast with 4.9% in OECD countries. Despite this, the PHI market has been expanding from 0.4% of total health spending in 2013. The Ministry of Health aims to strengthen the role of PHI in Bulgaria with the goal of reducing OOP payments. However, PHI markets can also raise concerns about inequities in access to healthcare services based on insurance status, it is therefore essential to develop a regulatory framework to minimise the risks and maximise the benefits of PHI.
Spending of providers of medical goods is relatively high, while spending of ambulatory providers is markedly low compared to other OECD countries
Hospitals contributed the most to health expenditure in 2023, 37%, comparable to the OECD average of 39% (Figure 4.4). On the other hand, providers of ambulatory care only accounted for 16% of spending, lower than in any OECD countries, and below the OECD and neighbouring EU5 averages (26% and 22%, respectively). Still in the context of providers, the second largest contributor to spending were retailers and other providers of medical goods, accounting for one‑third of total health spending, double the OECD average. The structure in the 2025 NHIF budget remained unchanged, with the largest share, 44% of total spending on services and goods, being directed towards inpatient care, followed by pharmaceuticals and medical devices at 27% (Republic of Bulgaria, 2025[1]). Primary outpatient care and specialised outpatient care each receive slightly over 7% of the total NHIF budget.
Note: Data refer to 2023. “Other” includes ancillary service providers (e.g. patient transport and laboratories); health system administration, public health and prevention agencies; households in cases where they provide paid long-term care (LTC); and atypical providers, where healthcare is a secondary economic activity. 1. 2022 data.
Source: OECD Health Statistics 2025.
Hospitals in Bulgaria have three main funding streams: 1) the NHIF (via the 28 RHIFs) based on clinical pathways, 2) the Ministry of Health through its various programmes and for activities outside the scope of health insurance, and 3) co-payments paid by patients covering services not included in the clinical pathways. Hospital spending by healthcare service is strongly dominated by inpatient care, with 94% attributed to this type of service in 2023 (Figure 4.5). This is significant considering that, on average, hospitals in OECD countries spend 62% in inpatient services, with this figure being around 73% in the case of neighbouring EU5 countries. The remainder is spent on day care, with almost no spent on outpatient services, vastly below the OECD average of 24%. This is the result of clinical pathways requiring a minimum hospitalisation of two days for reimbursed procedures.
Note: “Other” includes preventive care activity; pharmaceuticals if dispensed to outpatients; and unknown services. 1. Includes ancillary services. 2. 2022 data.
Source: OECD Health Statistics 2025.
An estimate for primary care spending may be derived from the sum of general outpatient care, dental outpatient care, home‑based care and prevention. In Bulgaria, in 2023, this amounted to 15% of total health expenditure, slightly higher than the OECD and neighbouring EU5 averages (Figure 4.6). However, a greater share of this is the result of general outpatient care (9% of health spending) in the case of Bulgaria, while preventive care constituted only 1% of health spending, similar to OECD countries.
Note: Data refer to 2023. 1. Spending on general outpatient care can include pharmaceuticals. 2. 2022 data.
Source: OECD Health Statistics 2025.
Ambulatory physicians, including general practitioners and dentists are largely self-employed. General practitioners earn income from NHIF payments based mainly on capitation and fee‑for-service (for services such as preventive screening and immunisations). Outpatient specialists and dentists are paid fee‑for-service. General practitioners and specialists also earn from user fees and direct payments. Some contracted physicians in public or private centres receive salaries plus bonuses tied to work volume. Hospital physicians are salaried usually with bonuses tied to work volume. Other health workers in the public system are also salaried. Many specialists split their time between private outpatient practice and public inpatient facilities.
Budgeting relies on historical trends
Bulgaria relies on historical budgeting, basing estimates for annual spending on past experience, policy areas, and budget programmes (strategic documents and action plans). However, a recent move is taking place to replace this practice to align budgeting with targets. NHIF operates on a stand-alone budget based on a national framework agreement negotiated with the Bulgarian medical, dental, and pharmaceutical unions, where volumes and prices are specified. The budget includes a “buffer” item that may be used for unforeseen needs to guarantee financial viability. In late March 2025, Parliament approved the National Health Insurance Fund (NHIF) budget for 2025 alongside the state and social security budgets. The NHIF budget, set at EUR 4.7 billion, reflects a 16% increase compared to 2024, though its expenditure structure remains largely unchanged. Bulgaria will need to continue shifting budgeting practices in from historical trends towards an approach based on targets, value, and priorities if it is to build a more efficient, quality-oriented health system. In this context, the NHIF can play a key role by engaging in strategic purchasing to, for example, promote adequate medicine use or support the shift from inpatient to outpatient care when appropriate.
Better allocation and use of resources would increase efficiency
A very cursory way of illustrating how the healthcare system is performing in terms of input costs and outcomes is to plot current expenditure on health against the rate of treatable mortality. On this metric, compared to countries which spend similar levels on health per capita, Bulgaria displays worse outcomes and higher treatable mortality rates (see Chapter 2). Bulgaria should address over-reliance on expensive hospital care and step up efforts to shift provision to outpatient care and preventive and primary care. However, despite a stated objective to strengthen outpatient care, Bulgaria has witnessed an expansion of hospital care, partially driven by private sector growth: it has the highest hospital admission rate in the EU at 339.9 per 1000 population in 2022. The average length of hospital stay is relatively short (4.9 days in 2022) (European Observatory on Health Systems and Policies, 2024[2]), likely due both to the high prevalence of acute hospital beds and clinical pathways predefining the length of stay. Referral quotas also serve as deterrents to accessing outpatient care (See Chapter 3). Shortages of healthcare professionals, notably general practitioners and nurses, hamper access to primary care services, potentially increasing inefficient use of hospital care. In addition to the strategies addressing medical graduates, measures should be taken to increase job satisfaction and retention of the existing healthcare professionals, by increasing their roles and responsibilities in the overall healthcare system.
Important gains in efficiency can be made in the pharmaceutical sector
Though the smallest in the EU, the market has grown, and the pharmaceutical industry is one of the fastest growing sectors of the Bulgarian economy, in part due to economic growth and high pharmaceutical prices and spending. Pharmaceutical spending is increasing in absolute value and per capita. Reference prices are derived from the lowest manufacturer prices registered across 10 countries (Belgium, France, Greece, Italy, Latvia, Lithuania, Romania, the Slovak Republic, Slovenia and Spain). Insured individuals pay the difference between the NHIF reimbursement levels and the reference (retail) price out of pocket. In 2022, pharmaceutical spending accounted for 33% of total health spending, double the OECD average. Outpatient medicines accounted for more than two‑thirds of all OOP spending. To increase efficiency and transparency of the reimbursement process in Bulgaria, health technology assessment (HTA) was introduced in 2015 as a mandatory procedure for inclusion of medicines in the benefits package. Initially, the National Centre of Public Health and Analyses carried out activities on health technology assessment of medicinal products. Since 2019, this activity has been carried out by the National Council on Prices and Reimbursement of Medicinal Products, which is the regulatory body for medicinal product pricing Despite the adoption of a broad set of measures since 2015, however, HTAs have not managed to control pharmaceutical spending or to enhance drug therapy efficiency and effectiveness. Bulgaria is in the process of developing a National Action Program against Antimicrobial Resistance for the period 2025-2028 which is pending discussion and adoption by the Council of Ministers. Furthermore, the draft programme has been updated in accordance with recommendations from the Directorate‑General for Health and Food Safety (DG SANTE). Generic substitution has not been implemented, with prescription forms having the option for the treating physician to specify whether the treatment may be provided through a generic counterpart. Despite this, many Bulgarians opt for branded products, which contributes to the observed patient spending. Considering this, and the fact that there is no mandatory INN prescribing or prescribing of the lowest-cost medicines, there is considerable scope for improving the efficiency of pharmaceutical spending overall and, subsequently, financial protection in Bulgaria. With the recent system-wide adoption of the NHIS, Bulgaria aims to monitor closely and tackle several wasteful spending occurrences in the healthcare system. For example, as of 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, to increase the efficiency of the spending of the public resources.
While total number of doctors is high, stronger efforts in roles, salaries and working conditions of nurses are needed to increase recruitment and retention Bulgaria has 4.6 physicians per 1 000 population in 2023, above the OECD and neighbouring EU5 averages (3.9 and 3.8, respectively) (Figure 4.7), with levels rising since 1990. The number of medical graduates has also increased substantially. In 2023, Bulgaria had 31 medical graduates per 100 000 population, which if three times higher than 10 graduates per 100 000 population in 2013 (Figure 4.8). On the other hand, this increase was rather slower in most OECD countries with the OECD average rising from 11 to 14 graduates and the neighbouring EU5 average rising from 13 to 16 graduates.
With 4.4 nurses per 1 000 population, Bulgaria has among the lowest density of nurses when compared to the OECD countries (OECD average: 9.1%) and, while this figure is higher than the 3.6 per 1 000 population observed two decades prior, the progress is slow and highlights the need for new approaches to catch up to the OECD average (Figure 4.7). In 2019, after protests for better pay and improved working conditions, increased minimum starting salaries for nurses working in state hospitals were negotiated nationally. However, dissatisfaction with salaries and working conditions still make it hard to attract and retain nurses. Emigration, ageing and uneven regional distribution are key challenges for the entire Bulgarian health workforce, particularly in primary care.
Note: Data refer to 2023 or nearest year. The OECD average is unweighted.
Source: OECD Health Statistics 2025.
Note: A large number of medical graduates are international students in some countries (e.g. Bulgaria, Romania, Latvia, Ireland, the Slovak Republic, Hungary and Czechia). 1. Data excludes international students, resulting in an under-estimation. 2. Latest data from 2022.
Source: OECD Health Statistics 2025.
Despite the relatively high density of physicians, some specialties still experience shortages
In Bulgaria, 13% of physicians were generalists in 2023, compared to 21% on average in the OECD, though similar to the neighbouring EU4 average (14%) (Figure 4.9). In addition, a serious shortage of healthcare professionals specialising in oncology and palliative care – both doctors and nurses – impairs access to cancer care (OECD, 2023[3]). Availability of oncologists (1.95 per 100 000 inhabitants in 2016 according to the latest available data) is among the lowest in the EU. According to the Bulgarian Medical Association register, there were about 3.3 medical oncologists per 100 000 population in 2023 (OECD/European Commission, 2025[4]). Shortages of specialists affect the whole chain of treatment of oncological diseases (including pathologists, anaesthesiologists, rehabilitation professionals and specialists in imaging, and palliative care). Palliative care does not exist as a separate specialty for healthcare professionals including doctors and nurses (see section on palliative care).
Note: Data refer to 2023 or nearest year. EU4 refers to Czechia, Hungary, Poland and Slovenia. 1. Includes non-specialist doctors working in hospitals and recent medical graduates who have not started specialty training. 2. Latest data from 2022.
Source: OECD Health Statistics 2025.
Financial incentives and training opportunities aim to increase more balanced distribution of doctors and nurses
Uneven physician distribution across medical specialisations and low levels of nursing graduates challenge access to primary care. Bulgaria also faces difficulties in recruiting graduates to replace the ageing workforce in rural areas. To address this, working and financial arrangements for the state‑financed medical specialisations mentioned above were adjusted to allow more flexibility in choosing employment. While the aim is to attract and retain young physicians to certain specialties, it may have ramifications for regional accessibility.
In 2023, the number of nursing graduates in Bulgaria was 7.6 per 100 000 population compared to the OECD average of 45.7 per 100 000. Besides small numbers of students admitted to universities, poor working conditions and low salaries make the nursing profession unattractive. In response, minimum starting salaries for nurses in state hospitals were increased in 2019. Additionally, independent practices of physicians’ assistants, nurses, midwives, or rehabilitation therapists (with the required experience) were introduced in 2021 and may provide (individually or in groups) select nursing, health promotive and disease prevention services, including at patients’ homes. This change aims to increase access to primary care and make these professions more attractive. Bulgaria also developed a Strategy to increase the number of qualified nurses and midwives by at least 30% until 2030. For example, the number of places for nursing students has been increased for the academic years 2024/25. Steps have been taken to designate the specialty “nursing” as a protected specialty, thus exempting students from tuition fees. Bulgaria introduced the project “Promoting specialisation in specialties and in areas with a shortage of specialists”, which was developed and implemented by the Ministry of Health within the framework of the Human Resources Development Program 2021 – 2027. The aim is to achieve a more balanced distribution of medical specialists on the territory of Bulgaria by providing financial incentives to i) postgraduate trainees, with an established shortage of specialists in the territory of the country and ii) specialists , with the lowest provision of the relevant specialists. These specialists are infectious disease doctors, paediatricians, anaesthesiologists, and emergency room doctors. The project also promotes training for a postgraduate specialty in the healthcare system by nurses and midwives.
The state‑funded trainees in the specialty of general practice are provided with a monthly salary from the budget of the Ministry of Health in the amount of 2.5 minimum wages for the country for the entire period of their training. The Bulgarian Ministry of Health reported that the number of postgraduates in general medicine has increased from 308 in 2022 to 571 in 2024.
The NHIS supports healthcare professionals to manage some tasks digitally, further improvements in the NHIS can also increase access to care through teleconsultation
The National Health Information System has been built as the unified system serving as the backbone to integrate all health-related software applications (see Chapter 2). Through features like e‑prescriptions, e‑referrals, electronic health records, the NHIS enable more efficient service delivery. The National Health Strategy 2030 supported by Investment 5 of the NRRP envisages the construction of a National Digital Platform for Medical Diagnostics. This platform aims to cover digital imaging diagnostics across medical specialties, create a digital image database, and allow secondary processing using machine learning and neural networks. It will be integrated with the NHIS and the electronic patient record, intending to improve diagnosis and follow-up. Currently, the Ministry of Health signed the contract with a contractor to implement the digital platform in certain specialties such as radiology, skin diseases, paediatric diseases in 20 hospitals. This strategy is also considered as a way to retain specialists at hospitals. While these digital solutions offer opportunities for improving service delivery, the NHIS is currently used mainly for accounting, monitoring patient flows, drugs and medical devices and informing patients, and not to increase access to care through teleconsultations.
Bulgaria introduced the amendment to the Healthcare Facilities Act in October 2024 formally recognising telemedicine. This amendment regulates telemedicine, allowing for diagnostic and other medical activities to be conducted remotely using health information technologies. This regulation aims to expand access to healthcare services, especially in remote areas experiencing a shortage of healthcare providers. While a pilot implementation was done in a small town of 15 000 inhabitants, teleconsultation services are still to be upscaled at national level. Bulgaria should translate legislative actions to tangible improvements by modernising the NHIS by developing teleconsultation systems and introducing incentives to encourage remote consultations. Bulgaria can benefit from engaging healthcare professionals and patients in the development and implementation plans of teleconsultations to increase relevance, acceptability, and adoptability of the proposed approaches.
The management of communicable diseases like hepatitis C and tuberculosis further reflects the system’s ability to respond to long-term health challenges through sustained investment in surveillance, treatment programmes, and public health capacity. Vaccination programmes, in particular, offer a window into how effectively systems are resourced to deliver essential preventive services at scale, including during times of crisis. These areas collectively provide insight into how well the system is positioned to maintain performance in the face of both chronic and acute pressures.
Hepatitis C is a significant concern, Bulgaria should step up its efforts to monitor, prevent and control the spread of the disease
Bulgaria had one of the highest prevalence rates of hepatitis C in the OECD in 2022, 0.9%, almost double the OECD average of 0.5% and above the EU5 average of 0.4% (Figure 4.10). The dominant genotype (G) of HCV in Bulgaria is G1b, found in 59% of those infected (Flisiak et al., 2022[5]). The main risk groups are people who inject drugs, with 67.8% of HCV antibody prevalence among people who inject drugs (Hajarizadeh et al., 2023[6]). Direct acting antiviral treatments have been reimbursed since 2016, and treating patients with health insurance were facilitated in 2017 (Flisiak et al., 2022[5]). The national screening programme is expected to target people aged 40 to 65 (Flisiak et al., 2022[5]). Screening will also be carried out in risk groups such as prisoners, men who have sex with men, sex workers, ethnic minorities, and migrants.
Note: Data refer to 2022.
In 2021, a National Program for the Prevention and Control of Viral Hepatitis in the Republic of Bulgaria 2021-2025 was adopted and implemented. The programme is implemented with partial funding (treatment of viral hepatitis is not part of the national programme but is covered by the NHIF). Surveillance of viral hepatitis is conducted in the country as part of the surveillance of infectious diseases, and for 2024, an increase in the number of registered cases of hepatitis B and C is reported, due to improved registration. Epidemiological data about chronic hepatitis C prevalence is scarce and most studies are based on single‑centre studies, stressing the lack of information at national level and undermining the potential for effective preventive policies to address the issue (Pentchev et al., 2024[7]; Sperle et al., 2020[8]). Achieving the elimination goals of WHO 2030 are not considered realistic by experts with current diagnostic and therapeutic indicators as well as the lack of appropriate harm reduction measures to prevent new infections and the spread of infections in high-risk populations. Bulgaria should increase its efforts to develop surveillance systems to monitor the prevalence of hepatitis and develop policies addressing the healthcare needs of these populations.
Incidence of tuberculosis in Bulgaria has halved over the past decade, though further efforts are needed to address multidrug-resistant strains
The incidence of tuberculosis, as estimated by number of new and relapsed tuberculosis cases arising in a given year, decreased from 23.8 per 100 000 population in 2013 to 13.5 cases in 2023 (Bulgarian National Statistical Institute, 2024[9]). The tuberculosis control programme is characterised by the involvement of non-governmental organisations, including a range of activities such as locating of high-risk groups, increasing awareness and support for patients who are under treatment (Doan et al., 2019[10]). The “Open Doors” programme launches regular community campaigns at national level to increase awareness on symptoms and offers free‑of-charge tuberculosis diagnosis and treatment services. In December 2025, a tuberculosis screening programme was launched by the WHO Country Office in Bulgaria in partnership with the Ministry of Health, the National Centre of Infections and Parasitic Diseases, seven RHIs and the Bulgarian Red Cross (BRC), to screen refugees arriving from high-risk areas. Across seven participating regions, 89 suspected cases of tuberculosis were identified, leading to full diagnostic and medical care in line with national protocols (WHO News, 2025[11]).
In line with the WHO Sustainable Development Goals and the End Tuberculosis Strategy targets, Bulgaria aims to achieve tuberculosis elimination by 2050 with interim targets to reduce incidence and tuberculosis-related mortality by 40% in 2025, and by 90 and 95% respectively in 2035. Confirmed by the National Tuberculosis Reference Laboratory at the National Centre of Infectious and Parasitic Diseases in 2023, there are 11 cases of multidrug-resistant tuberculosis (MDR-TB) compared to 27 cases in 2013. To eliminate tuberculosis, Bulgaria should continue its efforts on tuberculosis prevention, diagnosis, and treatment with targeted intervention on multi-drug-resistant tuberculosis forms and among vulnerable groups.
Incentivising childhood vaccinations and promoting the health literacy of the population can support reaching the WHO targets
In 2023, vaccination rates for measles in Bulgaria stood at 91%, slightly lower than the OECD and the neighbouring EU5 averages (93%), and it is not sufficient to reach the 95% target stipulated by the WHO (Figure 4.11). Vaccination rates for diphtheria, tetanus and pertussis (DTP) reach a slightly higher 94%, surpassing the 90% WHO target. Various information campaigns during 2024 have led to improvements in vaccination coverage for measles and DTP. According to the national statistics, the vaccination rates for measles also reached 94% in 2024. Promoting health literacy of the population while increasing awareness and availability of healthcare professionals and health mediators will be essential to further increase vaccination rates. Also, the Ministry of Health, together with the Bulgarian Paediatric Association, has prepared recommendations for immunisation of children with chronic diseases, approved by the Minister of Health in 2024.
Note: Data refer to 2024. 1. Latest data from 2023. 2. Data refer to estimates. Lines indicate WHO minimum targets of 95% for measles and 90% for DTP.
Source: OECD Health Statistics 2025.
The increasing trend in adult vaccinations is promising, ensuring access to vaccines is key for further improvement
Vaccination rates for influenza have increased from 3.5% in 2019 to 15% in 2023, though this remains well below the OECD average of 51% and slightly below the neighbouring EU5 average of 17% (Figure 4.12). The overall positive trend is in line with increases across Europe and follows the introduction of the National Programme for Improving Vaccine Prevention of Seasonal Influenza 2019‑2022, which provided free vaccines for the target population, though it failed to meet its coverage targets. A new National Programme for Vaccination against Seasonal Influenza and Pneumococcal Infections in Persons Aged 65+ (2023‑2026) was approved in early 2023 to expand on this Programme. Its vaccination coverage goals for Bulgaria’s older population include achieving a 35% influenza vaccination rate for people aged 65 years and older, and a 15% vaccination rate for pneumococcal infections by 2026. According to the national statistics, the immunisation coverage (influenza and pneumococcal infection) among the target population (people aged 65 and over) has shown an increase from 7.8% in 2019 to 21.2% in 2024. The low numbers in 2023 were reported to be due to the low level of the vaccination objectives set in the program. The delivery of vaccines under the programme is by agreement between the manufacturer and the NHIF and is in accordance with the percentages set in the program. The vaccines are delivered to general practitioners and are not purchased from the pharmacy network.
Note: Belgium’s data excludes people in nursing homes. Iceland’s data covers people aged 60+. and the Slovak Republic’s data covers people aged 59+. 1. Latest data from 2022.
Source: OECD Health Statistics 2025.
The high volume of prescribed antibiotics raises concerns about antimicrobial resistance
Antibiotic consumption in Bulgaria is among the highest in the EU. Antimicrobial resistance (AMR) is a major public health concern in the EU, with estimates of about 35 000 deaths in the EU/EEA due to antibiotic-resistant infections and healthcare‑associated costs of around EUR 1.1 billion per year (OECD/ ECDC, 2019). Because antibiotic overprescription and overuse in humans are major contributors to the development of antibiotic-resistant bacteria, antibiotic consumption data are a useful tool to evaluate the risk of AMR and the efficacy of programmes that promote their appropriate use.
In 2023, antibiotic consumption in the community stood at 25.0 daily defined doses per 1 000 population per day in Bulgaria, higher than any OECD country and above the OECD average of 16 daily defined doses (Figure 4.13). Moreover, just over 60% of antibiotics consumed in Bulgaria are on WHO’s Watch list – antibiotics that should only be used for a specific, limited number of indications. Bulgaria is in the process of developing a National Action Program against Antimicrobial Resistance for the period 2025-2028. It is pending discussion and adoption by the Council of Ministers. Also, the draft programme has been updated in accordance with recommendations from the Directorate‑General for Health and Food Safety (DG SANTE). To address these challenges, Bulgaria is in the process of developing a National Action Program against Antimicrobial Resistance for the period 2025-2028. It is pending discussion and adoption by the Council of Ministers. The draft programme has been updated in accordance with recommendations from the Directorate‑General for Health and Food Safety (DG SANTE). Some of the programme’s goals include increasing public awareness on antimicrobial resistance and antibiotic use, reducing the incidence and associated costs of multi-resistant infections, and reducing the use of third-generation cephalosporins in hospital and outpatient care. Furthermore, it outlines objectives in the field of veterinary health including improving laboratory capacity, fostering the use of alternatives to antibiotics, and introducing biosecurity measures. These goals are aligned with the latest Council Recommendation on strengthening EU action to combat antimicrobial resistance under the “One Health” approach (2023/C 220/01) as well as the achievement of the 2030 targets for the antimicrobial resistance and the use of antimicrobials in human medicine. The NHIS aims to monitor prescription of antibiotics through e‑prescription feature.
Note: 1. Latest data from 2019. 2. Latest data from 2021. * Accession/partner country. Data refer to antibiotics prescribed in community setting only.
Source: European Centre for Disease Prevention and Control (ECDC) 2025 (for EU countries); ECDC 2021 (for the United Kingdom); OECD Health Statistics 2025.
The COVID‑19 crisis highlighted important shortcomings in Bulgaria’s preparedness and response to health outbreaks and other emergencies
In response to the COVID‑19 pandemic, the Bulgarian Government enacted a series of measures in alignment with the WHO recommendations and the International Health Regulations. Despite these measures, the pandemic highlighted and exacerbated existing challenges in the Bulgarian healthcare system. Bulgaria had the highest excess mortality rates (+17.2%) in relative terms (% difference from expected deaths) and the highest age‑standardised excess death rates (24.7 deaths per 10 000 population) across EU countries over the period of 2020‑2023 (ECDC, 2023[12]; Rangachev, Marinov and Mladenov, 2022[13]). Significant discrepancies existed in the impact of the pandemic at the regional level, with higher excess mortality in the peripheral areas. The high prevalence of the CVD burden in some regions was strongly correlated with the high number of excess deaths (Rangachev, Marinov and Mladenov, 2022[13]). Shortages of healthcare workforce, their unequal distribution and regional disparities in health infrastructures also contributed to regional inequalities (Rangachev, Marinov and Mladenov, 2022[14]). The most heavily affected regions during the COVID‑19 pandemic were those with fewer intensive care unit beds and fewer healthcare workforce. In addition, the vaccination rollout was one of the lowest with 30.1% of the population being vaccinated by the end of 2023, considerably lower than the EU average of 73% (ECDC, 2023[12]). Bulgaria’s response to the COVID‑19 crisis was suboptimal, underscoring the necessity to reinforce its capacity to prepare for and respond to future health shocks. This entails updating preparedness plans, more effective communication, and improved co‑ordination at the national and sub-national levels.
The pandemic also acted a catalyst for some changes in the healthcare system. The implementation of the National Health Information System was accelerated during the pandemic, given the critical need for real-time data and information systems. Some features such as e‑referrals and e‑prescriptions were introduced in the early phases of the pandemic (see Chapter 2).
Beyond the health outbreaks, Bulgaria has faced and responded to other shocks such as natural and climate‑related disasters and Russia’s invasion of Ukraine. Bulgaria has been hit by climate‑related disasters such as forest fires, floods and prolonged droughts during the summer in 2024, which was one of the hottest on record. Russia’s invasion of Ukraine triggered an energy crisis, and Bulgaria adopted measures swiftly protecting the economy from disruption and hardship. Recognising the importance of strengthening pandemic preparedness and response, the Bulgarian NRRP for 2021‑2026 includes major investments on modernising hospital infrastructures, national emergency aid system including air emergency systems, promoting recruitments and retention of healthcare professionals in rural and remote areas.
To effectively manage future challenges, Bulgaria should reinforce its efforts to promote health of the population and decrease inequalities. Promoting healthier lifestyle, increasing prevention activities, promoting health literacy of the population, and strengthening primary care systems can reduce chronic conditions and improve health and well-being of people. Bulgaria should make significant efforts on promoting trust in the healthcare sector and healthcare professionals. Increased measurement, transparency, and integrity can enhance trust and serves as counterbalance to misinformation and disinformation.
References
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[1] Republic of Bulgaria (2025), Law on the NHIF’s Budget for 2025, https://dv.parliament.bg/DVWeb/showMaterialDV.jsp?idMat=233618.
[8] Sperle, I. et al. (2020), “Prevalence of hepatitis C in the adult population of Bulgaria: a pilot study”, BMC Research Notes, Vol. 13/1, https://doi.org/10.1186/s13104-020-05158-3.
[11] WHO News (2025), WHO launches tuberculosis screening campaign for refugees living in Bulgaria, https://www.who.int/europe/news/item/02-12-2025-who-launches-tuberculosis-screening-campaign-for-refugees-living-in-bulgaria.