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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