AmCham Bulgaria Report: Health Reform in Bulgaria will be Achieved with Investment, Innovation, Motivated Professionals, Digitalization and Public-Private Partnerships

  • In order to have a healthy nation, Bulgaria needs a strategic approach and investment in innovation, prevention, screening and development of out-patient assistance, trained and motivated health professionals, as well as digitalisation.
  • The introduction of large-scale prevention and screening campaigns would save tens of millions of BGN for subsequent treatment and save lives
  • The AmCham report also points to the need for reforms in the funding model, more efficiency and transparency of spending in the health system, and quality communication to society.

Improving healthcare in Bulgaria requires a strategic approach, institutional dialogue and solutions to ensure sustainable investment, training and development of motivated health professionals, deployment of innovation, large-scale digitalization and transparent public-private partnership between different stakeholders in the country. These are part of the conclusions of the report “Healthcare as an Investment” presented today by the American Chamber of Commerce in Bulgaria.

AmCham Leaders’ quotes

“With this report, the American Chamber of Commerce declares to be involved in the public debate on health reform, which is a priority for both the state and every Bulgarian citizen. We also believe that healthcare is part of national security. It is the basis for developing Bulgaria’s competitiveness and improving the economic climate in Bulgaria”, said Olivier Marquette, President, AmCham Bulgaria.

“Investing in health must not be seen in a fragmented way, and be perceived as a mere financial and a cost. If we want to build a healthy and happy nation, we need to take a holistic approach to the health system that everyone has an interest in caring for. Our contribution to the topic contains both recommendations for improvements and calls for common action and communication between all institutions and stakeholders. Thanks to the analysis in the report, we invited strategic institutions, partners and stakeholders for dialogue and for inclusion in its conclusions and suggestions. A further step is common action and political will to make them happen,” further said Olivier Marquette.

“We are proud that many companies and experts from the American Chamber of Commerce have been involved in the preparation and drafting of the report. This Community project also aims to involve other partners and stakeholders with its impartiality and a super corporate approach, so that together we can start to solve the difficult health equation involving patients, healthcare professionals, government and taxpayers. We are confident that this is the right approach for future policies and decisions corresponding to the growing needs of patients. This approach includes qualitative and quantitative analysis of solid data, sharing with partners and institutions and following up on common action to implement the necessary change in the health sector,” stated Ruslana Toncheva, Managing Director for Bulgaria, North Macedonia and Albania, Johnson & Johnson (Janssen Bulgaria).

“This unique product combines the expertise of experts from American Chamber of Commerce members with the talent in data processing and analysis of the IQVIA Bulgaria team. We used a methodology that carried out a comparative analysis of the status and performance of the Bulgarian health system against the European health system. The picture obtained outlined the gaps and progress that will underpin strategic decisions and investment for reform in the health sector. We believe that a common focus and goal for all of us is to increase the efficiency of health services for more benefits for citizens and for a better and lasting life,” said Luca Chichov, Co-Chair of the Health Committee of the American Chamber of Commerce in Bulgaria and General Manager of IQVIA Bulgaria.

The report draws on data from OECD, the World Bank, World Development Indicators, NHIF, NSIs, Eurostat, IQVIA.

Executive Summary

The analysis “Healthcare as an Investment” shows that Bulgaria has made progress in the field over the last 20 years. This is directly reflected in increased life expectancy, a reduction in infant mortality, etc. However, our country is significantly lagging behind a number of key indicators compared to European average, such as preventable mortality, access to health services and medicines, decreasing numbers of general practitioners, inefficiencies in out-patient assistance, etc.

The Bulgarian health system is one of the key factors for a stable economy, a sustainable labour market with an ageing population, a favourable business climate in the country and the attractiveness of Bulgaria as an investment destination. The report’s in-depth analysis also shows the need for reforms to optimise and make efficient use of available resources, as well as the need to invest in health with a guarantee of long-term returns.

In addition, the report proposes sustainable solutions based on the analysis of the available data in Bulgaria, as well as showing workable examples of economically developed European health systems that could be adapted and implemented in Bulgaria.


5 concepts for improving our healthcare

The report of the American Chamber of Commerce in Bulgaria sets out at least five concepts, the implementation of which would bring medium-term improvements to the health system, and which would have a positive impact on the health status of the population, access to health services and welfare increase. These are:

  • Prevention, screening and innovative medicine;
  • Digitalisation initiatives
  • A shift from IT-healthcare to true Digital Healthcare;
  • The need for a real reform of the financing model of the system;
  • Effective use of European funds.

Each idea can contribute both to effective spending on health and contribute to improving the health of every Bulgarian citizen.

Prevention, screening and innovative medicine

Building on good practices from programmes from other European countries, it is estimated that the possible benefits of HPV-vaccination[1] could contribute to an increase of at least BGN 110 million in GDP. If a national bowel screening campaign is launched, this could lead to a reduction of 16 % of cancer cases and a 26 % reduction in mortality from this disease. The introduction of innovative medicines and prevention of diabetes can contribute up to BGN 250 million of potential savings.

Digitalisation initiatives

According to the report, the benefits of large-scale and targeted digitalisation of healthcare in Bulgaria will contribute to facilitating access to treatment and treatment for patients, improving the efficiency and costs of healthcare, increased accountability and transparency of costs, etc.

The report focuses on the benefits of telemedicine deployment, patient e-health card, e-referral, ePrescription and the possibility of holistic analysis of the state of health of the population.

Real digital healthcare

The report identifies 4 pillars of digital healthcare: strategy, legislative basis, IT infrastructure and system integration.

The strategy should include the full spectrum of direction and resources needed to identify health needs, through the identification of the full spectrum of digital health care, including data sources and analyses, and through dialogue with key stakeholders, design the overall digital roadmap by 2030.

The legislative basis includes the revision of the current legal framework, the introduction of an electronic file, regulatory changes with rights and responsibilities, as well as the definition of the IT framework, data protection and property rights.

IT infrastructure includes a comprehensive technical infrastructure as well as databases and data repositories, software bases, bases and standards of the database, as well as encryption and anonymisation.

Systemic integration is necessary to ensure the interconnectivity of the different components of the comprehensive electronic health system. It must ensure communication between different systems and databases, create unique identification numbers to ensure data match and shared ownership and responsibility of those operating it.

A real reform of the system financing model

The report outlines four main ways in which to reform the financing model of the health system in Bulgaria: systemic change, creation of innovative funds, more effective ‘health’ redistribution from taxes and excise duties collected, and prioritising health investments from European funds and mechanisms.

In particular, the systematic change, according to experts, includes the possibility of revising the NHIF model and changing the overall funding model in Bulgaria, drawing on good practices from the health systems of France, Germany, Switzerland, etc.

The creation of innovative funds would facilitate a more effective accumulation of treatment through innovative medicine. Similar mechanisms exist and operate in Italy, Scotland and Wales.

European funds

The report dedicates European funds to a specific theme because they offer short or medium term financial solutions for structural reforms in our health system and will benefit the national budget.

The report calls on the government and health partners to ensure that part of the 2021-2027 Multiannual Financial Framework funds implement a series of health projects (systemic changes, digitalisation, etc.).

NextGenerationEU is a package of recovery and resilience mechanisms with EUR 390 billion in grants and EUR 360 billion in loans. The opportunity he offers must be stated with a subsequent correction of the proposed projects in the Bulgarian Recovery and Resilience Plan, which would focus on the health care in Bulgaria.

As part of the MFF, EU4Health is another mechanism under the stimulus package for MFF 2021-27, providing EUR 5,1 billion to EU Member States. According to the report, these funds can be used to: better preparedness and reinforcement of rapid response capabilities; disease prevention and health promotion in an ageing population; digital transformation of health systems as well as access to healthcare for vulnerable groups.

Call for action
Investment and financing

The main focus is on filling gaps in the financing of Bulgaria’s health system. The report indicates that a first step is to increase overall investment in health to 10 % of GDP in order to start narrowing our gap with the EU average. An increase in public investment by the State is also needed to reduce the cost of co-payment for healthcare to less than 20 % (close to the EU average). New is the proposal to create a dedicated Innovation Fund to ensure early access to innovative medicines for patients.

Effective allocation of funds as a recommendation includes increasing the efficiency of health spending. The focus here is on the hospital segment and the need for transparent monitoring of costs and benchmarking among hospitals at first. The experts suggest carrying out a regular “horizon scanning” to assess and plan the potential budgetary impact of losing exclusive rights on medicines and launching new products.

Innovative funding focuses on redistributing funding from existing taxes and excise duties from health-affecting products (tobacco, alcohol) to direct health investments. Investments in health also need to be prioritised and channelled as part of EU funds (Recovery and Resilience Facility and EU4Health).

Strategic priorities to drive health forward

The report outlines four strategic areas that need to be structured and phased in through state health policy. These are investments in prevention and screening; stabilising labour force dynamics; improving outpatient care and introducing digital healthcare.

Investing in prevention and screening

Experience has confirmed that the prevention and timely detection of diseases reduce the costs of the health system and guarantee quality treatment and life for consumers. The report therefore proposes the establishment of wide-ranging, government-backed, targeted strategies to:

  • Prevention (vaccination programmes, including not only for coronavirus).
  • Early screening of population groups.
  • National Cancer Strategy. Establishment of a National Cancer Register.
  • Stimulating awareness among the population of the country and countering disinformation through educational communication campaigns (e.g. vaccination, nutrition, etc.).
Stabilising labor force dynamics

A key factor in a system is people — doctors, nurses and other professionals. The report therefore suggests providing comprehensive programmes to encourage young doctors to stay and work in Bulgaria. The report shows the need to address regional disparities in access to health services

Bulgaria needs to implement public-private partnerships (institutions, academia and business) to invest in medical education. Among the financial gaps in the system, there is a need to address and provide resources to address the pay gap for nurses and hospital staff.

Improving outpatient care

A combined prevention and screening approach with the development and strengthening of outpatient and outpatient care would help to improve the health status and quality of life of people in Bulgaria. The report also recommends seeking greater transparency on the tracking of hospital care costs and the reallocation of inefficiently spent resources to out-patient care.

Introduction of digital health care

Healthcare in the twenty-first century is inconceivable without digitalisation. Therefore, the report also proposes several steps for its implementation:

  • Establishment of a Roadmap for the Digitalisation of Health with a clear vision, priorities and steps by 2025
  • Finalise the full implementation of the ePrescription.
  • Revision of the legislative base to enable professional and publicly funded provision of telemedicine services
  • Harmonisation of public databases for the interconnection of data and registers.
Reference points in the report

The Bulgarian health system has made significant progress in some of the quantitative indicators. For example, our average life expectancy increased from 71,7 years in 2000 to 78 in 2018, as well as a more than tripled increase in health expenditure from BGN 523 million in 2003 to BGN 1,64 billion in 2019.

Despite that favourable data, Bulgaria is lagging behind on a number of key health indicators compared to the European average, such as in terms of demographic trends, health costs and specific health indicators.

For the period 2000-2018, Bulgaria recorded a strong deterioration of demographic trends. For example, the age dependency ratio (the ratio between the number of persons over 65 per 100 persons and those in the 15-64 age group) is constantly increasing: from 24 points in 2000 to 33 points in 2018.

Among the EU countries, Bulgaria is ranked 4th in terms of out-of-pocket co-payments of 39.3 %, “lagging behind” only Cyprus, Greece and Latvia.

At least 25 620Bulgarians[2]  could have been cured or rescued in 2017, according to the “preventable mortality per 100 000 inhabitants” indicator in the EU. Moreover, as regards critical health indicators, Bulgaria is in an extremely poor position. For example, the levels of strokes and hypertension in Bulgaria are more than 4 times the average European, as well as the level of ischaemic heart disease – more than 1,5 times. This is alarming data that needs to be addressed by specific measures, both reactive (treatment) and preventive (screening, etc.).

Systemic problems

The analysis also focuses on structural problems, the resolution of which requires a holistic approach — i.e. require solutions at national level in the long term. It is a well-known fact that between 250-300 doctors leave our country every year. The distribution of health professionals per 1 000 inhabitants is extremely uneven in the country. General practitioners in Bulgaria have decreased from 4 900 people (2012) to 4 200 (2018). More worrying is the comparison of the ratio of specialists to general practitioners in Bulgaria and in the EU. It is 5,9 in Bulgaria compared to 3,1 in the EU, which points to a reduction of GPs as a desired profession in Bulgaria and a shortage of general practitioners to monitor the health status of Bulgarian citizens.

Another major problem is the lack of a strategic policy to prevent morbidity and thus over-investment in hospital care. Between 2010 and 2018, Bulgaria’s hospital beds increased from just over 6 500 to nearly 8 000 beds. Another indicator demonstrating the lack of prevention is the increase in hospitalisation per 1 000 inhabitants per year. In Bulgaria, this figure is growing in absolute terms. The opposite is the trend in the EU: from 170 hospitalisations per 1000 inhabitants per year in 2009, to 167 in 2018.

Expenditure on prevention is also an indicator for which Bulgaria is lagging behind EU levels. In Bulgaria, about EUR 34 per capita is spent on prevention on average per year (which is 2.6 % of total health costs). While the average in the EU is about EUR 89 per European (which is 3.9 % of total health expenditure).


[1] HPV – human papilloma virus

[2] The indicator reports 427 inhabitants per 100 000 inhabitants, which, assuming that 6 000 000 people live in Bulgaria, results in 25 620 Bulgarians.