The Bulgarian government has faced criticism from all sides for its lack of reforms in healthcare despite a proposed record budget for the National Health Insurance Fund or 2025.
The National Health Insurance Fund (NHIF) will distribute a budget of nearly €4.8 billion in 2025, a record increase of 16.5% over 2024. The country’s oversized and highly inefficient hospital network will absorb almost half the healthcare revenue increase.
“Nothing will change in the healthcare system next year, and Bulgarians will get more of the same healthcare, paying 16.5% more. This is a legitimate consequence of the lack of reforms,” former health minister Stoycho Katsarov, now chairman of the civil organisation Centre for the Protection of Rights in Healthcare, told Euractiv.
Inefficacious resource allocation
Bulgaria maintains the most hospital beds in the EU after Germany despite a critical shortage of nurses and problems with preventive and pre-hospital care.
Criticism of the government for wasting taxpayers’ money on an inefficient hospital system rather than investing it in prevention and better medical care outside hospitals has intensified over the past 10 years.
There are 341 hospitals in Bulgaria, with a population of 6.4 million, almost all of which work with the NHIF, and the average occupancy rate is just 53%.
With each year, existing hospitals are expanding with new clinics and wards, opening 1,000 new beds, while new private hospitals are opening in parallel.
This leads to highly fragmented health services with deteriorating quality, mainly due to a deepening shortage of medical staff that cannot cover the needs of the growing hospital network.
At the same time, the Bulgarian government relies increasingly on private pharmaceutical companies to subsidise the local health system with increasing discounts on the prices of drug therapies due to a lack of sufficient funding.
Katsarov reminded that the Bulgarian government could find itself in a very difficult situation after the Constitutional Court abolished limits on the cost of medicines from hospitals, which left the NHIF without tools to control spending.
“This creates a risk for the budget,” he said.
Eurozone membership implications
Health spending could prove a serious problem for Bulgaria’s goal of joining the eurozone on January 1, 2026. The risk of the budget deficit exceeding 3% would violate the Maastricht criteria.
“The NHIF will end 2024 with a significant amount owed to the hospitals, and interest is owed on those amounts starting January 1, 2025. These additional costs are not anticipated in the new budget. Unfortunately, a whole year was missed to create control mechanisms involving patients, as well as to change the rules and increase the efficiency of spending,” Katsarov told Euractiv.
He added that the parliament could do some things in the draft law on the health budget for 2025, but passing the law won’t compensate for the lack of long-term policy on the part of the government.
NHIF budget dispute
There is serious disagreement within the National Health Insurance Fund about whether the government is succeeding in solving the system’s problems. The fund’s manager, Stanimir Mihaylov, argues that the budget is balanced and prudent.
His deputy, Nikolai Boltadzhiev, strongly criticises the budget framework.
“This NHIF budget is not good at all – a lot of money but no reform. We will not get better quality and more affordable healthcare,” Boltadzhiev says.
“There are imbalances. The crudest thing is that the hospital budget has not been proportionally increased. It has been increased by 16% on the condition that a very high workload is expected and there is a big shortfall this year. More money should have been allocated,” he says.
[Edited by Vasiliki Angouridi, Brian Maguire]