A conversation with Petya Georgieva from the Institute for Market Economics about the shortage of nurses in Bulgaria, the role of patients in the system, and how small, practical reforms could make healthcare work better.

In Bulgaria, healthcare is often associated with hospitals, doctors, and state-covered treatment plans. But real patient care happens elsewhere—at the bedside, where nurses administer medication, monitor conditions, and are often the first to respond. And here lies a central paradox, as Petya Georgieva from the Institute for Market Economics (IME) points out: “We have enough doctors—the problem is there’s no one to do the care work.”

That’s the starting point of the first analysis from IME’s new Health Policy Incubator—an initiative designed to help reshape the healthcare system around the needs of the patient. Or, as Georgieva puts it: “The question is how to put the patient at the center—so they can control where their money goes and have the right to a second opinion.”

Not every issue requires a full-blown system overhaul, she adds. “I’m not a fan of talking about systemic problems. Not everything needs a complete transformation. But there are things we can fix—and they’d make a big difference.”

We asked Petya Georgieva how and where better care might begin.

America for Bulgaria Foundation: What is the Health Policy Incubator at IME, and what kind of change are you hoping to spark through it?

Petya Georgieva: It’s an idea that’s been in the works for a long time—we just weren’t sure how to implement it. We already have a similar program at IME focused on the rule of law, so we thought there should be something like that for healthcare as well. We called it an “incubator” because we wanted it to feel a little lighter, not overly institutional.

There are many NGOs in the health sector, but most are focused on specific conditions—groups formed to defend the rights of patients with particular diagnoses. What we want is to speak about the patient as a taxpayer, as someone who pays into the system through health insurance contributions and expects real services in return. The big question for us is how to ensure that the patient is at the center of the system, that they can see where their money goes and have the right to a second opinion. That’s the vision we’re working toward.

ABF: IME has long advocated for transparency and efficiency in the use of public money. Where does healthcare fit into that?

P.G.: Healthcare is one of the sectors that consumes the most public funding and offers the least clarity in terms of what we get back. The National Health Insurance Fund alone spends close to 10 billion levs a year. When you add private expenditures, the total rises to 16 or 17 billion Bulgarian levs (nearly 10 billion US dollars). That’s an enormous resource.

And yet Bulgaria has the lowest life expectancy in the EU, very high rates of preventable deaths, and people dying from conditions that are routinely treated elsewhere. The money is being spent, but we’re not seeing the outcomes. That tells us something in the system isn’t working.

ABF: What would you name as the three most urgent problems in Bulgarian healthcare?

P.G.: First, the shortage of nurses, even though we have enough doctors. Second, the overwhelming dominance of hospital care, which has crowded out prevention and outpatient services. And third, the fact that patients are expected to act like experts—searching for information, second opinions, trying to navigate a complex system on their own. That’s not how it should be.

ABF: Why did you start with the issue of nurses? Do you see it as the clearest sign of deeper system problems?

P.G.: Yes, I do. We have doctors—but we don’t have caregivers. In reality, it’s the nurse who takes care of the patient. The doctor checks test results and gives a diagnosis, but it’s the nurse who is there, day to day. In Bulgaria, care has been left in the hands of doctors, because there are simply no nurses.

We also chose to start here because we believe it’s a problem that can be solved relatively easily. Nurses are underpaid. Many of them work multiple jobs. A lot of student nurses drop out before they finish their training. This is a fixable issue. Like I said, I don’t believe every problem needs a system-wide overhaul. But there are things that can be fixed—and fixing them would go a long way.

ABF: You propose doubling nurses’ salaries. Why do you think that’s realistic?

P.G.: First of all, the money is there. Just from this year’s increase in healthcare revenues, we could double the salaries of all 20,000 nurses. It’s a matter of political will. The government could say: this year we’re not raising reimbursement rates across the board—we’re allocating that increase to nurses. It might be technically challenging, but it’s absolutely possible.

And a mere 5 or 10 percent raise won’t change anything. People need to know what to expect if they choose this career. Right now, no one feels there’s a future—and no one believes anyone is thinking about them.

ABF: You have also explored shortening nurse training and adjusting the roles of nursing assistants. What would the system gain—or lose—from those changes?

P.G.: According to EU standards, training must last at least three years and 4,200 hours. In Bulgaria, it’s currently a four-year bachelor’s degree. We’re not suggesting a cut in content—just a more compact structure. There’s no need for wasted time.

The Ministry of Health is strongly opposed—they argue that shortening the program would devalue the profession. But in many other European countries, nurses train for three years, and that’s perfectly acceptable.

As for nursing assistants—right now, many of them are already doing nurse-level work without the qualifications. That’s not good for them, and it’s not safe for patients.

ABF: One of your proposals is to allow nurses to practice independently. What would that mean for patients?

P.G.: Legally, it’s already possible. There’s a framework for nurses and midwives to open their own practices. But hardly anyone does it.

There are two main reasons: first, nurses aren’t prepared or encouraged to become entrepreneurs. Second, the process is full of red tape—complex reporting to the health fund, legal and accounting hurdles. If they don’t get support, it’s not going to happen.

That’s a shame, because there’s so much they could do—home visits, chronic care, working with nursery schools or rehab centers. But unless the rules are simplified, we won’t see any of it in practice.

ABF: What should the government do to attract foreign-trained healthcare professionals?

P.G.: We need to make it easier for people to come and work here. When Ukrainian nurses came to Bulgaria, we didn’t let them practice—because they didn’t speak the language, or because the system was too complicated. Meanwhile, Poland welcomed them right away.

The global job market for nurses is extremely competitive. And we’re at the very bottom. No one will choose Bulgaria unless we make it easier. This shouldn’t be a taboo—it’s a matter of survival for the system.

ABF: Do you believe healthcare problems in Bulgaria can be solved—or at least eased—with smart reforms?

P.G.: Yes, absolutely. There are no unsolvable problems. Only death is unsolvable. Everything else depends on will, organization, and someone being willing to take responsibility.

ABF: Are you optimistic about the future of healthcare in Bulgaria?

P.G.: I am—things are changing, even if slowly. But they don’t change on their own. Someone has to push. Someone has to keep the pressure on. That’s why we do what we do—to keep the issue alive.

👉 Read the full analysis from IME: “10 Solutions to the Nursing Crisis in Bulgaria”
This report outlines concrete proposals on pay, education, regulation, and working conditions—based on years of dedicated research in health policy.

The Institute for Market Economics carries out its work with the long-term support of the America for Bulgaria Foundation.