site.btaAnalysis Shows Aging Population, Shortage of Medical Staff, Rising Costs in Bulgaria

A rapid report on Aging Bulgaria: Demographics, Healthcare Workforce, and Future Trends 2040-2050, published earlier this week, outlines the projected rate of increase in the population over the age of 65 in the country, the need for measures to stimulate birth rates, to retain doctors and nurses in Bulgaria, and for policies that address the needs of the next 20 years.

The rapid analysis made by Health Technology Assessment (HTA) aims to provide context, figures, and forecasts (in euro) to support the demands, decisions and health policy updates. The analysis is based on the modeling of publicly available data from the National Statistical Institute (NSI), Eurostat, the World Health Organization (WHO), the Ministry of Health, and the National Health Insurance Fund (NHIF).

Population

Bulgaria is experiencing rapid demographic aging, with the average age rising from 40.4 years in 2001 to 45.3 in 2024. The share of people over 65 has increased significantly, reaching 23.5% in 2021, and is projected to rise to nearly one-third of the population by 2050. At the same time, the working-age population is shrinking, while the overall population is expected to decline from 6.44 million in 2024 to 5.64 million in 2040 and to 5.39 million in 2050.

Rural areas are aging faster than cities, with regions like Vidin and Pleven showing the highest average ages and largest shares of elderly residents. In contrast, cities like Sofia and Plovdiv remain demographically younger due to migration of younger people and higher birth rates. 

Medical professionals

Bulgaria currently has 430 doctors per 100,000 people (around 27,730 doctors for 6.45 million residents in 2022). With an average doctor age of 51, about half of them, especially 75% of general practitioners, are expected to retire by 2040. To maintain current doctor-to-population ratios, the country will need to train and retain around 13,900 new doctors by 2040.

A similar challenge exists for nurses. Bulgaria has 4.2 nurses per 1,000 people, far below the EU average of 8.5. To close this gap, nearly 20,838 more nurses will be needed by 2040, and a total of 18,746 more by 2050. Addressing this requires expanded training, better retention, and task redistribution to prevent a severe healthcare workforce shortage.

Trends

The demographic structure of Bulgaria points to increasing pressure on the pension, healthcare, and social support systems, unless it is offset by higher birth rates, sustainable immigration, or policy changes. The trends indicate a persistent decline in the overall population, low birth rates, rising mortality among the older population, and continued net emigration.

Economy forecast

Between 2022 and 2040, Bulgaria is expected to lose around 650,000 working-age people, which will limit economic growth. While GDP may still increase, maintaining growth will require higher productivity. Labour shortages in key sectors are likely unless older people stay in the workforce or immigration is encouraged. A shrinking labour force may drive up wages but could hurt competitiveness. Without reforms, GDP growth may fall below 2% by the end of the decade, and per capita income could stagnate or decline by 2030. Managing fiscal pressure from a growing retiree population and shrinking workforce will be essential to ensure economic stability.

Healthcare forecast

Between 2016 and 2025, healthcare spending in Bulgaria, funded by the NHIF, has grown significantly from nearly EUR 1.8 billion to EUR 4.7 billion mainly due to increased service use, higher pharmaceutical costs (including for innovative cancer treatments), and inflation. Hospital services continue to be the main driver of these expenses. 

As the population ages, with people over 65 expected to comprise nearly 33% of the population by 2050, healthcare needs will grow, particularly for hospitalizations, chronic illness management, and long-term care. Even if per capita service use remains constant, the rising number of elderly individuals will lead to higher overall costs. Budget pressures will intensify between 2025 and 2030, although fiscal plans project more moderate growth in 2027 and 2028. 

Pharmaceutical spending remains a critical concern, and without stronger cost-containment measures, such as wider use of generics, price negotiations, and tighter prescription controls, it will continue to burden the system. To ensure sustainability, reforms are needed in the reimbursement process and budget planning must be guided by historical trends. 

Additionally, as wages in the health sector rise to retain staff, labour costs will also contribute to the expansion of the NHIF budget.

Fiscal and political implications

By 2030, if the NHIF budget reaches EUR 7 billion, current health insurance contributions may become insufficient unless rates are increased or new revenue sources, such as co-payments or targeted taxes, are introduced. Budget caps have helped control overspending, but ongoing budget overruns show persistent financial instability. With a rapidly aging population, expanding community and home care services could help reduce costly hospital treatments. Allocating 5-10% of the NHIF budget to preventive and long-term care could slow emergency care costs over time.

By 2050, more than one-third of the population will be retired or nearing retirement, significantly increasing demand for healthcare, pensions, and social care. With fewer people in the workforce, economic growth will face pressure unless mitigated by higher labour participation, automation, or internal migration. A shrinking tax base will have to support a growing number of retirees, creating strain on public budgets and pension systems. By 2050, nearly six retirees will depend on every ten working-age adults, meaning three out of four workers will support one pensioner, putting pressure on pension funds and likely prompting policy changes such as higher contribution rates or increased retirement age.

As the working population declines and the number of pensioners rises, government revenues will shrink while public spending on pensions, healthcare, and social services grows. This demographic shift will also require more long-term care facilities, geriatric health services, and age-friendly urban planning. The decreasing number of youth may lead to school closures in underpopulated areas, but also presents an opportunity to redirect resources toward improving education quality rather than expanding capacity.

Necessary policy decisions

Without efforts to boost birth rates, ensure greater participation of women and older workers in the labour market, and encourage selective immigration, demographic trends will continue to strain Bulgaria’s economy and social structure. 

Analysts point to the urgent need for policy measures that promote childbirth, attract and retain working-age migrants, and adapt the pension and healthcare systems to an aging population.