Nikolay Petrov, Bulgaria’s minister of health, explains the five cornerstones of the country’s health strategy moving forward and highlights the role of the Ministry in finding common ground between patients, the industry, healthcare professionals, and the National Health Insurance Fund.

What are the cornerstones of the Bulgarian health system and the philosophy behind it?

The philosophy of the Bulgarian health system is based on solidarity amongst all stakeholders and empirical evidence, which is certainly positive for patients but at the same time challenging for the state. It is stated in our constitution that the government must provide healthcare access to all Bulgarian citizens and our public healthcare system is well reputed in terms of openness and accessibility. In fact, I can confirm that any patient in Bulgaria can easily reach the highest level of experts within a very short period of time, which is quite unique compared to the situation in many other countries in Europe and beyond.

The Bulgarian healthcare system is composed of four different elements with different interests and concerns: patients, healthcare professionals, industry, and the National Health Insurance Fund (NHIF). The role and commitment of the Ministry of Health is to find the common ground between the aforementioned elements, thus ensuring the quality, sustainability, and access of the overall national health system. I strongly believe that such a balance is one of the main underpinnings behind the Bulgarian healthcare system. Maintaining harmony between stakeholders is a continuous duty of the Ministry and one of my main priorities as well as challenges as minister.

An ambitious Health Management Program 2020 was set up in 2014. What does this program hope to achieve?

The Health Management Program recommends five major and related guidelines. The first is the implementation of an electronic health system – “Ehealth” – which aims to integrate health data systems to provide the necessary information to the authorities, industry, and patients. The second guideline is ensuring the financial sustainability of the public healthcare system, especially considering the growing footprint of chronic diseases as well as the high costs of innovative medicines. The third guideline is overcoming the existing regional imbalances in terms of healthcare access and quality. Fourthly, a balanced generics’ substitution model needs to be deployed based on a stronger role for pharmacists. Fifthly, prevention and early diagnosis practices need to be better integrated into the health system in order to fight against the footprint of both communicable and chronic diseases, which not only reduce the costs of treatment but also enhances the patients’ quality of life.

In parallel, the Ministry of Health is strongly supporting medical education activities to ensure the quality as well as quantity of our healthcare professionals. A substantial number of Bulgarian physicians are practising outside of the country and, consequently, Bulgaria is suffering from a shortage of doctors – especially in remote areas.


To date what have been the major advancements and what still needs to be implemented?

We have already made a lot of progress in many aspects of the Health Management Program 2020. We have detailed and well-defined action plans to successfully advance in each of the aforementioned strategic healthcare guidelines.

In terms of prevention, we have developed several interesting programs to target the oncology and vaccination areas. Concretely, I am proud to confirm that Bulgaria has one of the highest rates of vaccination coverage in Europe, covering more than 95 percent of Bulgarians within the vaccination public health schedule.

However, the successful implementation of Ehealth remains one of the major challenges within the national health strategy. This program is a really ambitious initiative that needs rigorous preparation. Within a few months we will start using the electronic health file and after approximately eight months we will implement electronic prescriptions.

In terms of challenges, Bulgaria’s healthcare system still lags behind in some areas such as the mortality rate of children under five, which in 2015 was 2 to 2.5 per cent higher than the rest of Europe and has been designated as a top priority by your administration. How is the government addressing this healthcare burden?


There is a program that is fully designed to address this situation and it has been in place for more than five years already, being a legacy from former governments. This scheme aims to cover women in all stages of pregnancy, mothers, and newborn children up to the age of one. Several prevention practices have already been introduced such as screenings that target the most common illnesses suffered by newborns and pregnant women. Nevertheless, there is still a long way to go in this regard and my cabinet in the Ministry is fully committed to this subject.

What are the main challenges in terms of the financial sustainability of the National Health Insurance Fund (NHIF) and patients’ access to innovative treatment in Bulgaria?

Logically, innovation needs to be paid for and this is translated into higher prices, which can impact the financial modelling of our health fund. The NHIF’s budget in Bulgaria is done on a yearly basis and sometimes does not include the appearance of a new innovative medicine in the middle of the year for instance. Therefore, it is quite challenging to define an accurate budget and, at the same time, some medicines do not enter the reimbursement plan for that year.

Bulgaria selects the minimum price for prescription drugs through reference to pricing in other European countries. Do you believe that this system guarantees Bulgarian patients access to the latest treatments?

It is certainly difficult to find a balance between price and innovation. Obviously, the newest treatments are the most expensive and, since we select the lowest price according to external references, some companies decide not to launch some innovative medicines in Bulgaria.

How are you collaborating with the pharmaceutical industry to find a win-win pharmacoeconomic approach that ensures patient access to the latest treatments?

Finding the common ground that satisfies patient access needs, the NHIF’s financial sustainability, and industry profits is one of the main challenges of any public healthcare system.

We are very active in collaborating with the industry and with patients’ associations. Indeed, I am delighted to share that I am quite satisfied with the results obtained through such collaboration.

A wave of parallel exports has hit Bulgaria, putting supply in the country at risk. What is the Ministry of Health doing to curb this?

We are fully aware of this health hazard and we have already made several amendments within the medicines legislation to minimize it. Even though we do not have the right to prohibit the export of medicines, we have a duty to ensure their availability to fulfil the Bulgarian patients’ needs at any time and at any place.

Nevertheless, the industry has always been a supportive partner of the Ministry and remains so on this issue. The industry is working to supply higher quantities of medicines than what our population may need in order to minimize the negative impact of parallel exports.