Overview

Bulgaria has a compulsory social health insurance (SHI) scheme, with a single purchaser – the National Health Insurance Fund. Voluntary health insurance (VHI) plays a small role. Universal health coverage is regulated by law; however, between 11-12% of the population remains uninsured.

At 8.6% of GDP, health expenditure is on par with the World Health Organization (WHO) European regional average for the first time. Nevertheless, per capita spending was relatively low at US$ PPP 2391 in 2021, of which 65.0% was funded by public sources (primarily SHI contributions and taxes). Out-of-pocket spending in Bulgaria accounted for 34% of total health expenditure, more than double the EU average. OOP spending is a result of cost-sharing for most statutory services and direct payments for health services and medicines.

Efforts to address systemic challenges, such as effectiveness, efficiency, financial sustainability, population coverage, and equity, have faced resistance in the last five years. However, the COVID-19 pandemic acted as a catalyst for some change, including a centralized governance system for the pandemic response in 2020 and the introduction of e-referrals and e-prescriptions in 2021. Since then, reforms in the Bulgarian health system have focused on workforce shortages, improving coverage and access, especially for chronic care and in underserved and remote areas, and prevention. Future efforts are expected to address allocative efficiency, improve care access, and ensure equitable, sustainable regional services.