Women in Bulgaria are paying a higher price for the failings of the country’s healthcare system, which is increasingly dependent on older, poorly-paid female nurses and midwives.
Fifty-five years old, a nurse in Sofia laments that she does not have many younger colleagues. After all, younger nurses might cope more easily with the workload.
“Most of them go abroad,” she said. “Salaries are close to the minimum, especially in the provinces.”
“The institutions are aware, but they turn a blind eye because there are no staff. We can’t talk about quality healthcare; when a nurse cares for 30 to 50 people, it’s impossible.”
BIRN contacted the woman via a Facebook group rallying medical professionals to ongoing protests against poor working conditions and low pay in Bulgarian hospitals.
The European Union country’s healthcare system has been struggling for years with staff shortages and a lack of investment in infrastructure, the result of high rates of emigration, the legacy of COVID-19, and the failure of a string of short-lived governments to enact long-term reforms.
Women are disproportionately affected given they represent the overwhelming majority in nursing and midwifery; they work long hours for relatively low salaries.
Among patients, women again are paying a higher price, particularly those from marginalised groups like Roma and asylum-seekers as well as victims of domestic violence, for whom access to professional medical analysis is key to gathering the necessary evidence to convict the perpetrator.
Bulgaria’s healthcare crisis is not just a workforce crisis, experts say. It is a gendered crisis of access, protection, and dignity.
As younger women go abroad or seek work in other sectors, nursing is increasingly on the shoulders of older women; an estimated 20 per cent of all nurses in Bulgaria are of retirement age.
“The average age of a nurse is 54,” said Mariya Ivancheva of the Bulgarian feminist organisation, Levfem. “This is not only a system that is currently collapsing, but is reaching a point where the shortage will become significant because a lot of them are not just reaching retirement age but they themselves don’t have anyone to care for them.
“And very often they are also carers of elderly people, carers of their children’s children,” Ivancheva told BIRN. “So we’re talking about an entire system being on the shoulders of a number of women of retirement age.”
Emigration, low pay
The current incarnation of the Bulgarian healthcare system dates to the late 1990s, when hospitals were given the status of commercial institutions expected to turn a profit; support from the National Health Insurance Fund, NHIF, is linked to the number of patients treated and operations performed.
Critics say the set-up disadvantages hospitals outside the big urban centres of Sofia, Varna and Plovdiv, which receive fewer patients; it also gives an advantage to private hospitals, which receive a share of the NHIF funding.
With 419 nurses for every 100,000 people, Bulgaria has the fourth-lowest density of nurses in the EU and – alongside Croatia – the smallest number of caring personal [e.g. healthcare assistants, home-based personal care workers] in the bloc, according to a 2024 report by the European Observatory on Health Systems and Policies.
Roughly 500 doctors emigrate every year, according to the European Social Policy Network, with a survey by the Medical University of Varna showing one in two nurses considered emigrating, often to countries such as Germany, Austria and the UK where wages and standard of living are higher.
Women in healthcare in Bulgaria are paid less than their male counterparts, according to a Bulgarian government report reviewing gender equality in the country, reflecting not only a gender pay gap, but also a deeply gendered division of labour within the medical system itself.
A 2018 report by the Centre of Women’s Studies and Policies found that 80 per cent of nurses at the Plovdiv Medical University were women; a 2023 study published in the journal Sciences of Europe found that more than 97 per cent of nurses nationwide are women.
Antoniya Dimova, a professor of Healthcare Management, Health Systems and Policy at the Medical University of Varna, said 20 per cent of working nurses are actually in retirement.
“Two factors contribute to this: low pensions, forcing retired nurses to work, and staff shortages, creating high demand for personnel,” Dimova told BIRN. “Because there is no particular long-term policy in place to overcome this problem, when these retired nurses exit the system, many healthcare establishments, especially those in smaller towns and rural areas, will have to close due to lack of personnel.”
The average annual pension in Bulgaria is 3,611 euros, according to a 2024 OECD Pensions report.
A nurse in Bulgaria can expect to earn 7.6 euros an hour. According to a study conducted in 2022, almost one in four of those surveyed said they were unhappy with their salary.
In a 2023 report, the National Statistical Institute of Bulgaria said that the gender pay gap in health and social work was over 21 per cent.
The shortage of nurses often means midwives are expected to pick up the slack, despite not being recognised as healthcare providers under public health legislation or NHIF-funded programmes.
The Bulgarian Association of Health Professionals in Nursing said nurses and midwives are also burdened by red tape.
“The staffing crisis, combined with increasing administrative requirements from the NHIF, has rendered the core functions of healthcare professionals meaningless,” Maria Chipileva of the association explained to BIRN.
“In other words, midwives and nurses are unable to perform the preventive and therapeutic activities within their competencies and are instead burdened with administrative tasks. This reduces the quality of healthcare services and directly harms both patients and healthcare professionals.”
Forced to go private
Changing the situation requires government action, but with Bulgaria holding a staggering seven parliamentary elections since 2001, no government has held on long enough to enact any meaningful reform.
In 2024, a plan to invest 50 billion euros in healthcare was paused until 2030, despite Bulgaria spending the least on healthcare per capita out of all EU member states and the infant mortality rate rising six per cent between 2023 and 2024.
The COVID-19 pandemic laid bare Bulgaria’s healthcare crisis, as the country registered the highest mortality rate in the EU. Under-resourced hospitals, exhausted staff and a fragmented management system struggled to mount an effective response.
“There are many public health issues that the pandemic has exposed and exacerbated,” said Dimova, citing, among other things, nursing shortages, a reliance on “out-of-pocket payments”, and a lack of integration in the system.
Many Bulgarians are forced to go private for treatment. In 2021, private medical payments accounted for 34 per cent of all spending on healthcare, the highest proportion in the EU and more than double the average.
Vulnerable communities often end up paying for healthcare; two-thirds of the Roma population, for example, does not have public health insurance, resulting in the startling fact that more than 82 per cent of Roma women have never had a mammography and more than 71 per cent never had a smear test when pregnant.
The health system is also failing refugees, the majority of them from war-torn Syria and Ukraine who have been granted temporary protection within Bulgaria. Some 92 per cent of the more than 50,000 Ukrainian refugees with protected status in Bulgaria are women and children, many of them traumatised by their experiences of the full-scale Russian invasion launched in February 2022.
The Asylum Information Database, an information database run by the European Council on Refugees and Exiles, said that, in Bulgaria, “special conditions for treatment of torture victims and persons suffering mental health problems are not available”.
Psychologist Kalina Yanova said “very few” psychologists in Bulgaria are trained to work with refugees.
“There’s a lot of trauma, a lot of PTSD within refugee populations,” Yanova said. “How can you have so many psychologists and psychotherapists?”
NGOs like the Council of Refugee Women in Bulgaria, CRWB, often step in to plug the gap, but waiting lists can be long. It is a “challenge”, said a CRWB social worker who gave her name as Dasha.
“We have cases of PTSD, depression, suicidal thoughts, panic attacks, extreme anxiety among these refugees, and they cannot be addressed without psychiatrists. I haven’t seen much [help] from the government.”
Impact on survivors of gender-based violence
Survivors of gender-based violence feel the crisis acutely.
According to the European Institute for Gender Equality, nearly 10 per cent of women in Bulgaria have experienced physical or sexual violence.
Evidence of physical harm must be assessed by a doctor, but many Bulgarian women say some in rural settlements are reluctant to get involved, while others lack the specialised training to conduct such examinations.
You Are Not Alone is a Facebook group with over 10,000 members sharing their stories of gender-based violence in Bulgaria.
Many express frustration at the failure of doctors to follow up on physical examinations following a police report; the shortage of psychologists and psychiatrists means many are deprived of counselling.
“If you turn up at your GP beaten and bruised, he’s supposed to give you the medical note to prove it,” said Preslava Fentham-Fletcher of the Wake-Up Foundation, a Bulgarian NGO that works to address domestic and gender-based violence.
“Every GP is obliged to do it, but they still refuse because they don’t know how.”
Some women in smaller settlements said their GPs refuse, said Fentham-Fletcher. “So they have to go to a specialist criminal doctor, which they don’t have in their region, because there’s like three or four of these types of places in Bulgaria.”