Bulgaria’s healthcare reform faces challenges

Since 2009, the Bulgarian government has begun attempts to reform the country’s ailing healthcare system, including the closure of hospitals operating below capacity and the introduction of a three-pillar health insurance system, with mandatory and voluntary elements, and public and private insurers.

The poor healthcare system makes the need for reform pressing. The 2009 Euro Health Consumer Index by the Health Consumer Powerhouse ranked Bulgaria last of 33 countries with the worst score.

  • The health of Bulgarians is among the worst in Europe, with smoking and alcohol abuse widespread. Obesity is also a major problem. In 2009, the average life expectancy at birth in Bulgaria was 73.0 years, compared to an average of 78 years in European Union (EU) countries;
Life expectancy at birth for males and females in Bulgaria, the European Union (EU-27) and selected EU countries: 2009

Source: Euromonitor International from World Bank.

  • Government plans were met with protests by healthcare workers in February and March 2010, further fuelled by payment delays from the state health insurer to healthcare providers;
  • In March 2010, Health Minister Bojidar Nanev – a key reform advocate – resigned amid corruption accusations. The charges related to allegedly excessive and over-priced quantities of anti-flu medicines purchased during the AH1N1 flu scare in October 2009.


  • Consumer spending on healthcare increased by 21.4% in real terms between 2004 and 2009, as incomes grew and Bulgarians faced the need to compensate for the deficiencies of state-funded healthcare. High consumer spending on healthcare takes away from potential spending elsewhere: in 2009, Bulgarians devoted 4.1% of their consumer spending to healthcare, compared to an average of 3.7% in EU countries;
  • In the 2009 Euro Health Consumer Index in cooperation with the European Commission, Bulgaria had the lowest scores of 33 countries surveyed for patient rights and information, outcomes of treatment, range of services provided and drug availability;
Euro Health Consumer Index ranking and score for Bulgaria and selected countries: 2009
Ranking out of 33 / score out of 1,000

Source: Health Consumer PowerhouseNote: The EHCI 2009 groups 38 indicators of quality into six categories: Patient rights and information, e-Health, Waiting time for treatment, Outcomes, Range and reach of services provided and Pharmaceuticals. Each sub-discipline is weighted for importance to provide the overall Index score.

  • A change in regulations in 2009 ended the widespread practice of pharmacies selling prescription medicines as over the counter (OTC) products. Stricter controls and higher fines have hit Bulgaria’s lucrative pharmaceuticals market;
  • Healthcare workers in Bulgaria took industrial action in early 2010, protesting against government plans to close under-staffed and poorly equipped hospitals in remote areas. Protests were also held over frequent delays in payments from the National Health Insurance Fund to healthcare establishments and pharmaceutical distributors. The reforms will make the system more efficient and transparent;
  • The need for healthcare reform is illustrated by the high number of Bulgarians without health insurance – an estimated 1.7 million in January 2010. This adds to the negative effects that the poor health of Bulgarians has on the economy and the business environment. There is higher public and private spending on the treatment of serious illnesses, while employers face more absences due to illness and the risk of social instability is increased.


  • Protests are expected to continue throughout 2010. Plans to introduce an indoor smoking ban for public areas in June 2010 were abolished by the government, citing the challenges facing entertainment venues amid the recession as the reason;
  • A national health portal was launched in March 2009 as part of an e-health programme, allowing for patient records to be accessed online by health professionals. The government plans further e-health tools to be introduced in 2010-2012;
  • A new Minister of Health, to be appointed in April 2010 is expected to be ‘even more decisive’ with healthcare reform, according to a government statement. Officials hope to introduce a three-pillar health insurance system, including a mandatory basic element and a voluntary element, as well as greater participation from private health insurance providers, by the