Arkadi Sharkov: Low Health Insurance Contributions and Growing Hidden NHIF Deficit Threaten the System

The health insurance contribution in Bulgaria is 8%, while the average level in the EU varies between 11% and 13%. Public health expenditures in our country are 4.99% of GDP – significantly below the European average of 8.05%. Bulgaria is “catching up” through out-of-pocket payments by citizens: in our country, these reach 34%, while in the EU they are only 17%, which, according to economist Arkadi Sharkov, poses a risk of serious social inequality.

At the National Congress of the Bulgarian Medical Association, Sharkov presented an analysis of the state of the system in the context of global crises. He emphasized that in terms of the number of physicians, Bulgaria is close to the EU (4.3 doctors per 1,000 people compared to 4.1 in the EU), but the acute shortage of nurses remains critical – the doctor-to-nurse ratio in our country is 1:1, compared to an average of 1:2 in Europe. Additionally, over 50% of Bulgarian medical professionals are over 55 years of age, compared to 35% in the EU.

Sharkov also drew attention to the growing “hidden” deficit of the health insurance fund, which includes unpaid activities to medical facilities and discounts from pharmaceutical companies. It amounted to BGN 810 million in 2023, BGN 1.03 billion in 2024, and is expected to exceed BGN 1.24 billion in 2025.

Another serious problem is the number of uninsured individuals. According to NHIF data as of May 2025, they number 1.12 million people, while according to the NRA, the figure is over 2.15 million. “The truth is likely somewhere in the middle,” Sharkov commented. Thus, potential losses for the system vary between BGN 0.56 billion and over BGN 2 billion, depending on which database is used.

Global crises – such as the COVID-19 pandemic, the war in Ukraine, and trade tensions between the US and China – directly affect access to medical equipment and materials. Shortages of raw materials, metals, chips, and components lead to higher prices for equipment and delivery delays, which block repairs and supplies, potentially delaying patient treatment.

“Bulgaria is not isolated from global processes – without adequate funding, strategic planning, and human resources policy, the system will remain vulnerable,” Sharkov concluded.