Health Metrics Analysis: Low Health Insurance Contribution Could Collapse the System and Cost BGN 50 Billion

If Bulgaria continues to maintain one of the lowest health insurance contribution rates in the EU, the country could face the deepest crisis in its modern healthcare history.

A new analysis by Health Metrics titled “The Cost of Inaction: Economic Analysis of the Consequences of Not Increasing the Health Insurance Contribution” shows that maintaining the current contribution level of 8% leads to acute staff shortages, hospital closures, increasingly high out-of-pocket payments for patients, and a dangerous restriction of access to treatment. This scenario is not a hypothesis, but a forecast based on official data and modeling up to 2040.

Staff Shortages and Limited Access

According to the analysis, the country risks losing between 5% and 10% of its doctors and up to 20% of its nurses—professions that are already in critical shortage today. In the most severely affected regions, this means the closure or merger of between 10 and 20 hospitals and up to 80 departments. For the population, this translates into longer travel times to medical facilities, more difficult access to specialists, and a real risk of lacking timely treatment.

In parallel, waiting times for examinations, surgeries, and diagnostic tests could increase by 30% to 80%. In some areas, the same equipment will have to serve twice as many patients, as technical modernization will be abandoned. This means more late diagnoses, more complications, and higher mortality from diseases that are preventable with timely intervention.

Bulgarian families will also suffer a heavy blow. Direct healthcare payments could reach 40% of total expenditures by 2040, and drug costs alone could increase by between 20% and 40%. This places more and more households at risk of a so-called “financial catastrophe”—a situation where healthcare costs push them below the poverty line. Prevention, which is already insufficiently developed and funded, will decrease by another 20–30%, meaning thousands of missed opportunities for early diagnosis.

How Much Does the Economy Lose?

The consequences for the economy are equally dramatic. If access to treatment deteriorates, up to 70,000 people could drop out of the labor market by 2040. The loss of productivity from untreated illnesses and sick leave could reach up to 1.5% of GDP annually—a double-digit percentage of the national economy over the entire period. The “cost of inaction” will exceed BGN 50 billion by 2040, measured in lost productivity, rising personal costs, staff shortages, missed benefits from prevention and early diagnosis, and the overall burden of disease.

The Alternative Scenario

The alternative scenario shows that increasing the health insurance contribution to 10% enables the system not only to avoid the crisis but also to undergo sustainable modernization. The additional revenue allows for covering the NHIF deficit, stabilizing hospitals, attracting and retaining doctors and nurses, updating equipment, and developing digitalization. Part of the funds can be directed toward prevention and screening—investments that save lives and reduce costs.

“The increase in the contribution is an investment—every BGN 1 leads to BGN 3 in social return and system sustainability. When considering the time value of money, society realizes cumulative benefits of over BGN 6 billion in additional revenue and investments in prevention and efficiency. The system’s income becomes predictable, access to treatment becomes equitable, and waiting times are significantly shorter. Most importantly, it ensures more years of life in good health, longer working capacity, and lower personal healthcare costs. Instead of a risk of system collapse, Bulgaria gains a chance for sustainable, modern, and fair healthcare,” said Mr. Arkadi Sharkov, health economist and managing partner at Health Metrics.