Bulgaria faced critical gaps in oncology service coordination, particularly in digital integration, with slow uptake of innovations in oncology impeding progress in cancer care. Patients often experienced fragmented care and delays between diagnosis and treatment stages. As a result, some patients lost confidence in the system, discontinued their follow-up or opted to pursue treatment outside the country. Despite the availability of telemedicine and digital health solutions, there has not been a systematic integration of these into oncology practice. Moreover, the absence of a comprehensive enabling regulatory framework hindered the coordination of efforts between government institutions, clinical stakeholders and innovation actors toward shared objectives in cancer care.
To address these issues, a memorandum of understanding and partnership (MoU) was signed in December 2023. The MoU brought together national ministries, clinical leaders, technology partners and civil society. The Ministry of Health and the Ministry of Innovation and Growth provided governance and resources, while the BJCN mobilized oncologists and clinicians. Further, the Digital Health and Innovation Cluster (a civil society and tech-policy NGO) helped initiate the hub concept and ensured private-sector engagement.
The MoU was signed as a joint initiative by the Minister of Innovation and Growth and the Minister of Health, together with BJCN leaders during the BJCN’s National Oncology Conference. It laid the foundation for a cross-sector digital health framework, prioritizing tele-oncology (mig.government.bg). For this, multidisciplinary working groups were formed, bringing together policymakers, oncologists and IT experts to launch pilot activities and to spur planning for a national oncology innovation roadmap.
Key follow-up actions include expanding tele-oncology services, initiating environmental readiness for platform deployment (e.g., PrOPA and the pilot Comprehensive Cancer Infrastructure), and drafting operational procedures and guidelines to govern remote consultations with regulatory preparedness. The partnership act of engagement also influenced legislative revisions: “telemedicine” was formally defined and recognized as a concept within health legislation under the Health Act, enhancing institutional support for digital oncology. The legislative revision shall reflect Bulgaria’s National Cancer Plan (published in the State Gazette, 2023) with updates of the plan under the establishment of National Cancer Mission Hub.
Enablers included strong political leadership and will (notably from Minister Milena Stoycheva and Minister Hristo Hinkov) and strategic alignment with EU policies, which provided external motivation and potential funding avenues (Governance, Financing). Additionally, clinical and academic advocates, such as BJCN experts and university leaders, were actively involved and provided credibility and continuity. The existence of digital health initiatives by BJCN and partner NGOs (and Digital Health Innovation Cluster-Bulgaria, National Patient Organization and Junior Achievement Bulgaria) allowed rapid scaling under the MoU framework (Resources).
Barriers: Translating the high-level agreement into concrete changes remains challenging. Initially, roles and funding responsibilities were not clearly defined, requiring additional coordination (Governance, Financing). Bridging different institutional cultures, i.e., the entrepreneur and tech-driven approach of the Ministry of Innovation vs. the health and regulatory focus of the Ministry of Health, took effort. Addressing legal barriers related to telemedicine, such as outdated regulatory frameworks, was essential. Moreover, sustaining momentum beyond the initial memorandum required ongoing multisectoral engagement, which was further challenged by the absence of alignment with overarching national health policy priorities (Service delivery).
While still in early stages, the partnership has already led to structural changes and is expected to yield further tangible reforms. A detailed action plan to implement tele-oncology nationwide is under development, and a dedicated telemedicine platform for cancer care is under scaling. The MoU’s framework will feed into the National Cancer Control Plan 2027, ensuring innovation and digital health are integral parts of it. It also positions Bulgaria to attract EU funding (e.g., from EU4Health or Digital Europe) to support these initiatives. As the establishment of the National Cancer Mission Hub in Bulgaria advances, the country is expected to formally integrate into the European Network of Cancer Mission Hubs, fostering sustained exchange of best practices, expertise, and policy alignment. Future developments must include the introduction of formal legislative or regulatory frameworks, such as amendments to national healthcare laws. These efforts will aim to support the institutionalization and reimbursement of telemedicine within oncology care pathways, ensuring long-term sustainability and system-wide impact.
Lessons learned: The implementation of the memorandum of understanding in Bulgaria highlights how strong political leadership and a shared vision across sectors proved essential in catalyzing cross-ministerial collaboration and driving momentum for digital health reforms. The involvement of committed politicians and leaders from different ministries ensured institutional buy-in and visibility at the national level, and the presence of pre-existing digital health initiatives and professional networks served as valuable foundations for rapid mobilization. The alignment with European Union policy frameworks could provide strategic direction and opened opportunities for financial and technical support. International guidance also strengthened the legitimacy and scalability of national efforts. However, outdated legislation and different institutional cultures pose significant barriers to digital innovations and telemedicine implementation, underscoring the need for adaptive policy to support innovation in healthcare delivery. Sustaining engagement beyond the initial policy launch requires clear role definitions, continued intersectoral coordination, and integration with national health strategies and regulatory acts. Without these, the risk of fragmentation and gaps in digital integration remain, potentially undermining long-term impact.
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