Bulgarian healthcare workers launch protest over low wages

Young doctors, nurses, and medical students have launched open-ended protests demanding significant pay rises, better working conditions, and improvements in training and education, as Bulgaria’s healthcare sector faces a deepening staffing crisis.

The demonstrations, which began in major cities including the capital Sofia, Plovdiv and Varna, are drawing renewed attention to long-standing underfunding in the health sector, while many hospitals are struggling to stay open due to a lack of staff and resources.

The current wave of protests follows an unprecedented strike by staff at state psychiatric hospitals earlier this year, which led to salary increases of more than 30%. However, regular hospital staff are unlikely to see similar gains, as their salaries are not directly financed by the state but rather by the hospitals themselves.

Protesting under the banner “Future in Bulgaria”, the medical personnel are supported by the Bulgarian Union of Medical Specialists. Employees of national transfusion and haematology centres joined the protest movement in June.

Government support, but limited action

Health minister Silvi Kirilov, also a medical professional, has expressed support for the protesters but stressed that the government’s options are limited.

“I understand their concerns, but I cannot promise solutions that are beyond my authority. We must act step by step to ensure any change is financially viable and sustainable,” he said, adding that the ministry would initiate negotiations.

The sector has been operating without a collective bargaining agreement for over a year, due to ongoing disputes between hospital managers and medical staff over minimum wage thresholds.

State aid and EU rules

Despite many large hospitals being 100% state-owned, the government cannot legally impose wage policies on them, as they operate under commercial law.

“Hospitals are independent employers and can set their own wage policies, provided they comply with minimum insurance thresholds,” explained Maria Sharkova, a leading medical law expert, in comments to Euractiv.

She added that Bulgaria’s EU membership significantly limits the state’s ability to directly subsidise hospitals for wage-related expenses, as such action could be considered illegal state aid under EU competition rules.

“This could trigger sanctions from Brussels for breaching state aid regulations,” Sharkova warned.

Below-standard pay

The expired collective agreement had set minimum starting salaries at €1,000 for doctors, €750 for nurses, and €460 for hospital aides, but some hospitals have failed to meet these benchmarks, citing a lack of revenue.

Young doctors are now calling for their base salaries to be pegged to the national minimum wage, currently €545. They demand a starting salary of €2,000, or 3.5 times the minimum wage.

Healthcare professionals, including nurses, midwives, lab technicians, and physiotherapists, are demanding starting wages of €1,800, or 150% of the national average salary.

Protesters are also calling for legislative guarantees to enforce minimum wages in the sector, including mandatory sanctions for non-compliant hospitals.

“The Health Ministry has a key role to play in transforming the healthcare system, and we believe that those working in it have the right to participate in shaping its future,” the protest organisers wrote in an open letter to Minister Kirilov, obtained by Euractiv.

Worsening workforce shortages

Bulgaria’s healthcare system is facing a growing personnel gap, particularly among nurses. According to official data, the number of nurses fell to 28,600 in 2023. This is a decline for the tenth consecutive year, with an estimated shortage of around 30,000 professionals.

While the number of doctors has slightly increased, the nurse-to-doctor ratio has fallen below one, raising concerns about the quality of medical care. The country currently has 444 doctors and 115 dentists per 100,000 people, figures that are above the EU average but mask severe regional disparities.

In May, the director of the municipal hospital in Pernik, a city of 60,000 people, resigned due to a critical shortage of midwives, which led to the closure of services at the local maternity unit.

Calls to raise the taxation

The Bulgarian Medical Association has repeatedly called for an increase in the health insurance tax paid by citizens to bolster the public healthcare fund. This could help stabilise struggling regional hospitals and improve compensation for healthcare workers.

However, the proposal remains politically sensitive, and the government, backed by a fragile four-party coalition, has yet to endorse such a measure.

With discontent spreading and no clear resolution in sight, the Bulgarian healthcare system risks further fragmentation, as medical professionals seek better prospects abroad and regional hospitals continue to lose vital staff.

“The Bulgarian Medical Association insists and has already launched an initiative for increasing the share of GDP allocated to healthcare. Without such a change, all other measures will remain partial and short-term,” the organisation said in a statement.

[Edited by Vasiliki Angouridi, Brian Maguire]