Superbugs and the Economy: Europe and Bulgaria Trapped by Antimicrobial Resistance

Arkadi Sharkov is a macroeconomist from the Expert Club for Economics and Politics (EKIP) and co-founder of the Health Metrics platform, with experience in health policies aimed at both the public and private sectors. He holds a Master’s degree in Public Policy with a specialization in International Trade and Law from Maastricht University and the United Nations University. He is currently a doctoral student at Sofia University “St. Kliment Ohridski” and a lecturer at the Higher School of Insurance and Finance. He is a member of the Board of Directors of the “Brain Health Council.”

Antimicrobial resistance (AMR) has long ceased to be a topic only for microbiologists—it is becoming a structural risk for European economies. In the EU, resistant infections lead to over 35,000 deaths annually and generate additional costs for healthcare systems of approximately €1.1 billion per year. Behind these numbers lie longer hospitalizations, more expensive therapies, and lost years of productive life—all at a time when Europe is already aging and struggling for every point of productivity.

The Silent Pandemic with a High Price

According to the Organisation for Economic Co-operation and Development (OECD), the annual economic cost of AMR in 34 developed countries (including EU/EEA members) reaches approximately $66 billion—roughly $28.9 billion in direct healthcare system costs and $36.9 billion in economic losses in the form of lower productivity and labor market withdrawal. This means that the “silent pandemic” of resistance competes in effect with a medium-scale recession, yet without being recognized as such in public debate.

Several new models for global scenarios up to 2050 show that under a “no change” scenario, healthcare costs due to resistant infections could more than double, and losses to the global economy could be measured in trillions of dollars annually. Particularly vulnerable are economies with already strained health budgets and low trust in institutions—a profile that fits many countries in Central and Eastern Europe.

At the micro-level for hospitals, the picture is even more specific: treating a patient with a resistant infection can cost between $10,000 and $40,000 more compared to a similar infection from a sensitive pathogen due to more expensive medications, intensive care, and extended stays. Thus, AMR directly “eats up” resources that could be invested in prevention, innovation, or infrastructure modernization.

Bulgaria: High Usage, High Resistance, Slow Policies

Bulgaria is a paradoxical example: healthcare spending as a share of GDP is relatively low, but antibiotic use was among the highest in the EU for a long time. ECDC data for 2021 show total antibiotic consumption in outpatient care in the range of over 20 defined daily doses (DDD) per 1,000 people per day—in the upper segment of the European rankings. Simultaneously, Bulgaria maintains higher-than-average EU resistance levels for a number of key bacteria-antibiotic combinations.

This model—many broad-spectrum antibiotics, frequent use “just in case,” and a historical tolerance for self-medication—leads to a situation where the country is a “net importer” of resistance: high levels of resistant strains but limited capacity for a systemic response. An adopted, updated, and realistically implemented national plan for AMR continues to be lacking, and policies are limited to awareness campaigns and isolated regional initiatives.

The last three years, however, have brought the first serious institutional changes. The introduction of mandatory electronic prescriptions for antibiotics led to a rapid decrease in sales—in some early observations, the drop exceeded 25–30% within weeks. More structural analyses of IQVIA data show a steady cumulative decline of approximately 10% in antibiotic sales in general practice between 2022 and 2024, or over 1.1 million fewer packs. This is an important signal that a relatively simple regulatory measure—digital control and traceability—can change the behavior of both doctors and patients.

Despite this, Bulgaria remains without a comprehensive, funded, and cross-sectoral “One Health” strategy. The lack of a sustainable national plan means that measures are fragmented: separate in the hospital sector, separate in general practice, with a limited focus on antibiotic use in agriculture and minimal emphasis on the environment.

The “Broken” Market for Antibiotics

The economics of pharmaceutical manufacturing further complicates the picture. From a public perspective, new antibiotics should be used as little as possible—as “fire extinguishers” for the most severe cases—to prevent resistance from emerging quickly. From a business perspective, this means low sales and poor returns despite very high risk and a long development period. The result is a classic market failure.

Over the last decade, small and medium-sized companies have led the wave of innovation, but many of them have proven financially unviable immediately after regulatory success. Today, the global pipeline of new antibiotics targeting priority resistant pathogens remains limited—significantly smaller than that for oncology drugs, even though mortality and the economic burden of AMR in some scenarios approach those of oncology. This means that without a change in the reward model for innovation, the system will continue to rely on old molecules that are gradually losing their effectiveness.

Targets, Vouchers, and “Subscription” Models

Against the backdrop of these trends, the European Union has intensified its political focus on AMR. In 2023, the Council of the EU adopted a recommendation with specific targets for 2030: a 20% reduction in total antibiotic use, ensuring that at least 65% of use consists of first-line antibiotics, as well as a substantial reduction in the incidence of key resistant pathogens (MRSA, resistant E. coli, K. pneumoniae, etc.).

The latest ECDC report from 2024 shows that progress is mixed: there is a slight decline in some categories, but in others—such as Klebsiella pneumoniae—the incidence of infections increased by about 61% during the 2019–2024 period. In other words, Europe is not yet on a trajectory that guarantees the achievement of most 2030 targets.

In parallel, a reform of EU pharmaceutical legislation is underway. The European Commission proposes the introduction of a transferable data/market exclusivity voucher (TEV) for developers of new antimicrobial drugs—a tool that extends the exclusivity period for another drug in the portfolio and can be sold between companies. The idea is to create a “pull” incentive that compensates for the limited sales volume of the new antibiotic.

In parallel, so-called subscription or Netflix models are being discussed, where states pay a fixed annual amount for access to a new antibiotic regardless of the quantities actually used. This makes the company’s revenue predictable and decouples it from volume, while clinicians can remain strict in their antibiotic policy. The first pilots already exist in countries like the UK and Sweden; a debate is ongoing in the EU on how such models can be scaled at the Union level.

Where is Bulgaria in this picture?

Bulgaria is part of this European context but remains a reactive rather than a proactive player. Electronic prescriptions showed that regulatory and digital tools can realistically reduce the overuse of antibiotics. The logical next step is the creation of a national AMR program, integrating:

• ambitious targets for antibiotic use, aligned with European ones;
• funded surveillance and laboratory capacity for resistance;
• strict hospital policies for reserve antibiotics;
• strict policies and requirements against healthcare-associated infections;
• control and phased restriction of use in animals;
• participation in pan-European schemes for “subscription-based” provision of new antibiotics.

The economic logic is clear: relatively limited annual investments in these areas can prevent future costs for thousands of additional hospitalizations and lost working years. For a country with a limited health budget, AMR is a typical example of the cost of inaction—the price of passivity is higher than the price of reforms.