Bulgaria

This chapter provides an extended look at health politics and the compulsory health insurance system in Bulgaria. It traces the historical development of the Bulgarian healthcare system characterized by the introduction of social health insurance, which after the establishment of communist rule in Bulgaria after World War II was replaced with a state-run healthcare system. Starting in 1989, Bulgaria underwent a transition to democracy and free market economy. This triggered structural healthcare reforms, including the re-introduction of social health insurance with both public and private provision. However, as privatization was permitted without effective price control mechanisms and conditions for entry into the public insurance system, out-of-pocket payments became extensive, especially for pharmaceuticals. The main reform challenges have been to close the coverage gaps and secure sufficient financing by stipulating selective contracting with hospitals, strengthening the control on pharmaceuticals, and tightening the collection of insurance contributions. While political debates were initially structured along traditional left–right political party lines, since 2001 new center-right parties have shaped Bulgarian health politics. Nevertheless, the reform process still suffered from lack of continuity, and private interest groups have successfully blocked cost-containment policies.