Overview

Bulgaria’s health system is highly centralized and based on a compulsory social health insurance (SHI) scheme, with a single purchaser - the National Health Insurance Fund (NHIF). By law, all citizens and residents should be insured but according to varying official estimates, up to 14.8% of the population (over 1 million people) may have been uninsured in 2019. The statutory benefits package covers a range of primary, secondary, and tertiary level health services and goods. However, cost-sharing for most services covered by the SHI and direct payments for excluded services, and particularly medicines, means that Bulgaria recorded the highest share of out-of-pocket health spending (37.8%) in the EU in 2019. Bulgaria’s health spending been growing since 2000 and reached 7.1% of GDP in 2019 but per capita spending remains very low in comparison to the EU average.

The ability to implement major planned health reforms has been uneven, at times due to resistance and legal action on the part of stakeholders. Nevertheless, obligatory Health Technology Assessment (HTA) for all new medicines on the positive list was successfully introduced in 2015 and contributes to improving cost-effectiveness and efficiency. Other positive developments include changes to health sector working arrangements to increase the attractiveness of the medical and nursing professions (thus helping with staff retention and recruitment); changes to hospital management and pharmaceutical pricing regulations; and the introduction of e-referrals and e-prescriptions in 2021.