Bulgaria’s healthcare system is nearing collapse due to long-standing budget constraints, according to a new analysis from health analytics firm Health Metrics. The report warns that persistently low health insurance contributions could cost the country €25 billion by 2040, further weakening an already fragile economy.
The study projects hospital closures, a deepening shortage of medical specialists, and tens of thousands of people leaving the labour market as untreated health problems rise. These outcomes, it says, are likely if the government maintains the current 8% solidarity-based health insurance rate.
“If Bulgaria continues to uphold one of the lowest health insurance contributions in the EU, the country may face the deepest healthcare crisis in its modern history,” the report states.
Catastrophic Expenditure Risk
The findings are echoed by Nikolay Brunzalov, President of the Bulgarian Medical Association, who notes that Bulgaria allocates just 5% of its GDP to healthcare—the lowest share in Europe. “We are absolute champions, but in a negative sense. Doctors work under chronic underfunding, yet still deliver world-class medicine,” he said.
According to the report, Bulgaria could lose between 5% and 10% of its doctors and up to 20% of its nurses, worsening already severe staffing shortages. Smaller towns and poorer regions are most at risk, with up to 20 of the country’s 340 hospitals facing closure.
Patients would likely see longer travel times, fewer specialists, and treatment delays. Waiting lists for consultations, surgeries, and diagnostic tests could grow by 30% to 80%. In some regions, outdated diagnostic equipment may be forced to handle double the workload, leading to late diagnoses, medical complications, and higher mortality from preventable diseases.
Households also face growing financial pressure. Medicine costs alone could rise by up to 40% by 2040, pushing more families into “catastrophic health expenditure”—where medical bills drive them below the poverty line. Preventive care, already under-resourced, could shrink by another 20% to 30%, resulting in missed opportunities for early intervention.
The economic impact could be substantial. Declining access to care may force up to 70,000 people out of the labour market by 2040, while productivity losses linked to untreated conditions could reach 1.5% of GDP annually. Overall, the “cost of inaction” is estimated at more than €25 billion by 2040.
An alternative scenario outlined in the report suggests that raising health insurance contributions by 8% to 10% could stabilise the system and finance long-term modernisation.
Persistent Structural Challenges
A major obstacle to reform is the large number of uninsured Bulgarians. More than 1.2 million people—out of a population of 6.4 million—do not pay health insurance contributions. This persistent problem is linked to Bulgaria’s large grey economy, estimated at around 34% of GDP.
Many citizens work without formal employment contracts and do not declare income, yet the solidarity-based system grants them free emergency care. This places additional financial pressure on already strained hospitals.
Brunzalov argues that the government should gradually raise the insurance rate by 0.5–1% each year, or increase it directly to 10%, similar to Romania’s model.
Rising Pressure on the Pharmaceutical Sector
Pharmaceutical companies have also criticised the government’s growing reliance on mandatory rebates to cover healthcare financing gaps. The Association of Research-based Pharmaceutical Manufacturers in Bulgaria (ARPharm) warns that these rebate requirements shift the system’s deficit onto industry and threaten access to innovative treatments.
The National Health Insurance Fund (NHIF) is projected to spend €1.55 billion on medicines in 2026, but the state expects pharmaceutical companies to return at least €450 million. Industry leaders argue this practice masks a hidden healthcare budget deficit and risks further limiting access to modern therapies for Bulgarian patients.
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