BAPZG and SBMS: Categorically Against Hospital Organizations' Proposals for Changes to the 2026 NHIF Budget

The Bulgarian Association of Healthcare Professionals (BAPZG) and the Union of Bulgarian Medical Specialists (SBMS) sent an open letter to the media regarding the proposals of the Bulgarian Hospital Association (BHA) and the National Association of Private Hospitals (NAPH) for changes in the financing of medical specialists’ remuneration.

We provide the Open Letter without editorial intervention:

BAPZG and SBMS express their categorical disagreement with the amendments proposed by the Bulgarian Hospital Association (BHA) and the National Association of Private Hospitals (NAPH) regarding the draft 2026 NHIF budget.

Healthcare professionals—nurses, midwives, rehabilitators, medical laboratory technicians, and X-ray technicians—are one of the main pillars of the healthcare system. These specialists are the ones who stay by the patient’s side around the clock when the doctor is busy with other responsibilities, when relatives cannot be with the sick, and when fear, pain, and loneliness are strongest. It is these professionals who provide continuous care and attention to patients, taking upon themselves all their experiences from the first to the last day of treatment. Unfortunately, performing all these tasks is becoming increasingly difficult due to the acute staff shortage in the system. Today, the situation is not just difficult or alarming; it is critical.

We have repeatedly warned that over half of those working in the field are of retirement or pre-retirement age. Two-thirds of healthcare professionals are over 53 years old; this in itself is a “red flag” regarding optimal modern healthcare. There is a shortage of over 30,000 medical specialists, which means that in reality, every healthcare professional, regardless of where they work, takes on a workload many times greater than normal. The lack of personnel leads to a deterioration in care due to overload and exhaustion, reflecting mostly on the patient and their loved ones. The emigration of trained and qualified personnel to other countries is not decreasing; on the contrary, it is increasing, driven by dissatisfaction, lack of adequate pay, lack of respect in society, and a reluctance to change the existing status quo.

These data are not just dry statistics; they reflect the reality of our collapsing healthcare system. If this trend continues and is not stopped, very soon there will be no healthcare professionals to care for patients, the elderly, children, and the most vulnerable members of our society.

Therefore, we categorically cannot agree with the proposals of the Bulgarian Hospital Association and the National Association of Private Hospitals for targeted funding in the form of scholarships only for newly graduated healthcare professionals. These will not only fail to lead to a positive change in the negative trends we have already mentioned, but will deepen them for the following reasons:

1. The proposals of the BHA and NAPH show a clear distinction between different groups of medical specialists based on age and professional criteria, which is a discriminatory measure in itself.

2. Such a change will generate serious social tension among medical specialists.

3. Such a method of financing devalues the accumulated experience of the specialists currently working in the system. Their loyalty to the profession is erased, their experience is marginalized, and this will lead to absolute demotivation on their part.

4. The consequences of potentially adopting such a proposal will catalyze a professional collapse in the system, undermining collegiality and creating an environment of inequality.

5. Another very important and significant problem we identify is the lack of an adequate mechanism for control and accountability of remuneration costs in medical facilities. There is a real possibility that managers of medical facilities will accumulate financial surpluses without being bound by the obligation to redirect them toward staff remuneration and improving working conditions, which distorts the purpose of public funding and demotivates teams. This means that healthcare professionals are left without guarantees of fair remuneration.

All this not only contradicts the fundamental principles of the Constitution of Bulgaria, the Protection Against Discrimination Act, and the European Social Charter, violating the principles of equality and social justice, but will also accelerate the staffing crisis in the sector.

In this regard, BAPZG and SBMS once again propose a vision and a proposal for an alternative, fair, and sustainable financing mechanism for healthcare professionals, which includes the following points:

1. The introduction of measures for extraordinary state intervention is the only possibility to stop the outflow from the professions and is an initial step toward the recovery of the healthcare system. The legal basis for extraordinary state intervention is provided by the critical shortage of healthcare professionals, which is a serious threat to the public interest, the quality of healthcare, and national security. According to the Constitution, the Health Insurance Act, and the Health Act, the state is obliged to ensure the functioning and sustainability of the healthcare system. European Commission decisions clearly identify healthcare personnel as a strategic resource, and Bulgaria has a commitment to meet European standards and expectations.

2. Creation of a National “Healthcare” Fund—a fair and transparent instrument. In addition to the guaranteed starting salary of €1,550 set in the 2026 budget, we propose the creation of a temporary National “Healthcare” Fund for a period of up to 10 years, financed directly from the state budget. Through the establishment of this fund, the state will pay a uniform, fair salary supplement to all medical specialists, regardless of the medical facilities in which they work, updated with the inflation index for each subsequent year. Additional remuneration will be paid based on qualification, professional experience, and the responsibility of the healthcare professionals, rather than according to the legal status of the employer. This will guarantee healthcare professionals financial incentives reflecting their real skills, knowledge, and contribution to patient care. When these funds are paid in a targeted manner by the Ministry of Health, rather than passing through the NHIF, the State assumes clear and direct responsibility regarding the working conditions and remuneration of medical specialists, while simultaneously preserving the basic principle of the health insurance model: “the money follows the patient.”

3. Introduction of clear control over the expenditure of funds for remuneration.

In this way, the vicious practice of shifting the burden onto the health insurance system will be avoided, and it will be guaranteed that the funds purposefully reach healthcare professionals.

The presence of strict control and transparency in the use of these funds—with medical facilities being obliged to provide accountability proving that the money was spent specifically on the remuneration of medical specialists—will build trust between institutions, society, and healthcare professionals. Last but not least, it will be a guarantee that these funds will not be misappropriated. Parallel to the financing of healthcare specialists, a sustainable model for professional development and continuing education for healthcare professionals will be maintained. In this way, they will be motivated to develop, grow in their careers, and, importantly, remain working in Bulgaria. This creates a perspective for young people to choose the medical profession and ensures interest in the “Healthcare” field of study.

Advantages of the approach we propose:

1. It does not violate the Constitution, as it does not create differences or discrimination between specialists based on employer or any other formal characteristic.
2. It does not create a contradiction with the Health Insurance Act, preserving the principle that “the money follows the patient,” due to the fact that a direct financial commitment has been made at the State level.
3. It directly corresponds to European directives and best practices for promoting the development and retention of healthcare personnel, without introducing administratively determined minimum remunerations through the NHIF, which would inevitably create complications and tension in the sector.

The approach we propose excludes discriminatory division by age, length of service, or workplace and guarantees equality, transparency, and predictability of the income of healthcare professionals, providing the opportunity for coverage of all health units by them. The fund should be subject to strict public and institutional control, with funds being spent solely on the remuneration of healthcare professionals, with the possibility of annual adjustment according to inflation and socio-economic indicators. This will ensure not only social justice but also motivation to attract and retain personnel, as well as opportunities for professional development.

Additional measures and vision for the future:

The increase in the labor remuneration of healthcare professionals is an important, but not the only, problem in the healthcare system waiting for a solution. For years, BAPZG has been proposing the accelerated introduction of legislative and regulatory changes to allow for the opening of independent nursing and midwifery outpatient practices funded by the NHIF, as well as the finalization of the national patronage care program covering the chronically ill and midwifery practices. It is necessary to integrate innovative models of nursing and midwifery care that meet modern European practices and guarantee the sustainability and competitiveness of the Bulgarian healthcare system. Last but not least, to achieve better healthcare and a lasting solution to the staffing problem in the system, a comprehensive healthcare reform must be undertaken.

In conclusion, we call upon parliamentary and government institutions, as well as society as a whole, to realize the critical importance of healthcare professionals and to take immediate, decisive, and sustainable legislative steps to guarantee their dignified remuneration, professional autonomy, and opportunity for development. Only in this way will we be able to guarantee quality health services for all citizens and strengthen social justice and the security of the country.

We call upon the National Assembly and all governing bodies:

To adopt a legally regulated and constitutionally compliant solution for the financing of healthcare professionals, guaranteeing fair conditions for all working healthcare professionals.

To restore the leading role of the Ministry of Health in personnel policy so that the State bears the responsibility for the formation, development, and retention of medical specialists.

To ensure maximum transparency and control over the funds spent, so that every lev/euro reaches the specialist for whom it is intended.

To allow professional autonomy for nurses and midwives, including the possibility of establishing outpatient practices outside of hospitals and the right to enter into contracts directly with the NHIF, in order to ensure accessibility for health-insured persons to medical care consistent with the powers of medical specialists described in Ordinance No. 1 on independent activities.

To finalize the establishment of a national system for patronage nursing and midwifery care, which in turn will ensure accessibility for people in the most remote regions of the country.

To categorically reject proposals from other structures that contain even the slightest hint of discrimination against healthcare professionals.

To undertake immediate talks to begin a comprehensive reform of the healthcare system, without which a higher degree of satisfaction on the part of medical specialists and patients cannot be achieved.

BAPZG and SBMS remain true to the conviction that only through open dialogue, partnership with institutions, and a reasonable state policy can lasting results be achieved!