Comment by Emilia Milcheva:
The scandal with SANS developments related to the health fund began as a question of who should not manage it. But it should end with an answer to the question of why the Bulgarian healthcare system is producing more and more patients, instead of more healthy people.
The political debate was limited to a personnel dispute surrounding the management of the NHIF. However, it should not remain within these limits. The revelations of a former SANS employee brought to the fore problems that journalistic investigations and expert analyses have been describing for years – about the weak control over the spending of public funds, drug schemes and the uncontrolled expansion of the hospital network.
Because the problem is not only who manages the NHIF with its budget of 5.2 billion euros for 2026, almost two and a half times larger than that of the Ministry of Interior. Nearly ¾ of its expenses are for hospitals (47%) and for drugs and medical devices (26%). But control lags behind the money, and the rules allow the system to grow without any connection to the health needs of society.
How it all started
On June 17, "Democratic Bulgaria" called on the government to withdraw the candidacy of Dr. Asen Medzhidiev for deputy governor of the NHIF. According to the formation, Medzhidiev brought the previous manager of the fund, Prof. Momchil Mavrov, into its leadership, and replacing one with the other means only "replacing one person from the facade with another", in which "most likely the schemes will continue".
Two weeks later, the SB raised the stakes. In parliament, the co-chairman of "Yes, Bulgaria" Ivaylo Mirchev stated that there were developments in the State Agency for National Health Services related to the activities of Mavrov and Medzhidiev, and asked a series of questions to the ruling party. "Is it possible that Mr. Mavrov and Mr. Medzhidiev put pressure on the former director of the "Medical Supervision" Agency to increase the number of beds in specific private hospitals in order to drain money from the NHIF? And is it possible that this is just one of the cases that SANS worked on, but all these developments were covered up?!", asked Mirchev.
The next day, in an interview for the media platform "Off Air", former SANS employee Yasen Tokuschiev made several revelations that can be summarized in one conclusion: institutional control is blocked by political pressure. The story of the former head of the "Healthcare" sector outlines a mechanism in which decisions with a huge financial impact can be made under pressure despite the lack of reasonable grounds, and inspections that have begun – are terminated. Some of his claims are related to the opening of new hospital beds in private hospitals, and others – with schemes to divert expensive drugs, the discovery of which cost him his job.
The more, the more
Judging by the number of hospital beds, Bulgaria should be one of the best-equipped healthcare systems in Europe with its 338 hospitals, 148 of which are private.
According to the latest Bulgarian Health Profile for 2025, prepared by the European Commission and the OECD, the country follows a strongly hospital-oriented model that is expanding. In 2023, Bulgaria will have 8.6 hospital beds per 1,000 population - over 50% more than the EU average. The EC analysis found that the system is inefficient - discharged patients are more than twice the EU average, while bed occupancy is only 57%, below the EU average of 68%.
The paradox is that the state has long had a tool that should prevent such growth - the National Health Card. The Ministry of Health itself has already admitted that if it is updated correctly, it will become clear that in large cities there are redundant hospital structures with bed utilization below 45%. According to Minister Katya Ivkova, it is the updated card that should provide grounds to limit the opening of new hospitals and activities that duplicate existing ones, as well as allow the NHIF to choose, based on clear criteria, which medical institutions to conclude contracts with. But what is promised is not what is done.
Why is it necessary to open new hospital beds, after the OECD recommends that Bulgaria reduce its dependence on hospital treatment and strengthen primary and preventive care? In almost all European countries, the number of hospital beds is decreasing due to the shift of treatment to outpatient care, while in Bulgaria it continues to grow to almost 57 thousand by 2025.
These also include those nearly 1,800 in the “Heart and Brain” chain, for which the former SANS employee explains that they were discovered despite the reluctance of the Executive Agency “Medical Supervision” to give the green light.
“There are no explicitly stated criteria in the law that would limit “Medical Supervision”, there are many significant flaws in issuing complex assessments (they are the basis for the discovery of a hospital, b.a.)”, states the former counterintelligence officer.
Disease as a business
The impressive hospital capacity does not translate into better health outcomes. On the contrary - Bulgaria continues to be among the countries with the lowest life expectancy and the highest overall mortality rate in the EU. Cardiovascular diseases are the cause of almost 2/3 of deaths, while the average for the EU is 33%, almost two times lower. And mortality from cardiovascular diseases in Bulgaria has been recording the slowest decrease in the EU over the last decade, the European Commission has found. In second place after them is the mortality rate from cancer.
And with cancer drugs, some of the biggest abuses are carried out, since the therapies are expensive - one package reaches thousands of euros. With targeted or immunotherapies, the prices are even higher.
An investigation by journalist Valya Akhchieva "Trading with Death?" three years ago revealed the terrifying truth that not all cancer patients in Bulgaria are given medicine. She proved that according to documents, the same package of cancer medicine was administered in two hospitals to two patients and paid for by the health insurance fund - and this is proven by the electronic verification system (SESPA). Of course, only one of them received it…
"The Bulgarian patient's medicine is often in the Netherlands and Germany. We don't know what is in the infusion banks (of cancer patients)". This is part of Tokuschiev's interview, in which he confirms - three years after Akhchieva's investigation - that some cancer patients in Bulgaria are practically not... treated. There is no other way to qualify the fact that a medicine, reported as administered to a Bulgarian patient, turns out to be traced to Germany or the Netherlands. The medicine was paid for with public funds, and subsequently the hospital made a profit in its own interest - endangering the patient's life.
According to Tokuschiev, the legislation is structured in such a way that “adequate control and transparency regarding the export of medicines is impossible“. The systematic shortages of medicines in Bulgaria, especially for diabetics, confirm this. He himself is leaving the National Agency for National Health Service. The reason is that on August 28, 2025, he was ordered to stop inspecting the drug warehouses of wholesalers for which there is evidence of fictitious commodity turnover by diverting medicines from the legal supply chain. “I receive a call from the director of the directorate: “Wherever you are, leave immediately, get out of there!”.
"Criminal syndicate"?
What's next? For the first time, a counterintelligence officer, an operational agent for ten years - and a sector chief for another five, speaks about a “criminal syndicate” in healthcare, for draining public resources from large hospitals, for an arbitration commission that always rules in favor of private hospitals, for serious interests of the MRF, for corruption and pressure in the National Health Insurance Agency...
The problem is no longer limited to the appointment of a former minister in two of Rumen Radev's offices as head of the NHIF. The schemes have been going on like this for years. The rules that allow a huge public resource to be distributed with such weak control need to be changed. The National Health Card should become a real planning tool, and the opening of new hospitals and beds should be subordinated to public needs. The movement of each package of expensive medicine should be traceable, and control over NHIF expenses should become real, not formal.
The problem is not in one appointment, but in a model that finances more and more hospitals and more treatment, which is why there are more and more patients. Who would dare to destroy it?