Topical Information

A working meeting between the leadership of the National Association of Municipalities in the Republic of Bulgaria (NAMRB) and the Minister of Health Katya Ivkova, Deputy Ministers Prof. Petko Salchev and Galya Alexandrova, as well as the Ministry’s team, took place today at the Ministry of Health building. The meeting was part of NAMRB’s initial discussions with the new ministers in the cabinet, focused on priority policies for municipalities.

Representing NAMRB were Deputy Chairperson of the NAMRB Management Board and Mayor of Dimitrovgrad Municipality Ivo Dimov; members of the NAMRB Management Board and mayors of Petrich Municipality – Dimitar Brachkov, Burgas Municipality – Dimitar Nikolov, Razgrad Municipality – Dobrin Dobrev, Karlovo Municipality – Dr. Emil Kabaivanov; Chairperson of NAMRB’s Standing Committee on Healthcare and Mayor of Targovishte Municipality Dr. Darin Dimitrov; Deputy Mayors of Sofia Municipality Desislava Zhelyazkova and Nadezhda Bacheva; Director of the “Demographic Policies, Monitoring and Coordination” Directorate at Burgas Municipality Maria Kumanova; Deputy Executive Director Teodora Dacheva; and representatives of the NAMRB team.

At the beginning of the meeting, Ivo Dimov thanked the Ministry of Health for its willingness to engage in dialogue and stressed that municipalities expect pragmatic solutions to issues directly affecting citizens and access to healthcare. He noted that NAMRB had prepared concrete proposals in several key areas – child and school healthcare, mosquito population control, sustainability of municipal hospitals, prevention of drug use among children, and implementation of outpatient care projects under the Recovery and Resilience Plan.

Dr. Darin Dimitrov, Chairperson of NAMRB’s Standing Committee on Healthcare and Mayor of Targovishte Municipality, emphasized that municipalities expect the new leadership of the Ministry of Health to be a partner with an in-depth understanding of the system’s problems. He highlighted the two most serious challenges for local authorities – child and school healthcare and the future of municipal hospitals. According to him, the shortage of nurses is already jeopardizing the functioning of medical offices in kindergartens and schools, especially in smaller settlements. Dr. Dimitrov noted that NAMRB maintains an active and constructive dialogue with the Ministry on all legislative and regulatory changes in the sector and expressed the Association’s readiness to continue supporting solutions aimed at improving the organization of child and school healthcare, securing medical personnel, and developing prevention and screening activities.

The Mayor of Burgas Municipality and member of the NAMRB Management Board, Dimitar Nikolov, stressed that municipalities are already making maximum efforts to attract and retain medical professionals, yet the shortage of nurses remains extremely serious. He gave the example of Burgas, where a residential building for doctors and nurses is being constructed, and where the municipality has formed a special logistics team to support the relocation of entire families – from transport and accommodation to finding kindergartens, schools, and extracurricular activities for children.

Nikolov also presented a project implemented in Southeastern Bulgaria covering 18 municipalities, under which 231 offices in schools, kindergartens, and pediatric practices are being renovated, while six prevention programs are being implemented and mobile teams are being created to compensate for the shortage of specialist nurses in more remote settlements. According to him, the shortage is particularly severe in mountainous areas, and the project is already being monitored by the European Commission and the European Investment Bank as a model for addressing the problem.

Special attention during the meeting was given to the growing problem of the use of narcotic substances, laughing gas, inhalants, and new psychoactive substances among children and young people. Nikolov emphasized that the first signs of the problem usually emerge at the local level – in schools, families, and local communities – which places municipalities in a key role regarding early prevention and response. He noted that different forms of local preventive structures and partnerships exist across the country, but their capacity is uneven and often insufficiently supported. According to him, the main difficulties are related to the lack of adequate methodological and expert support, limited funding, varying levels of school engagement, and the absence of a clear response mechanism when new risks and substances emerge.

Deputy Mayor of Sofia Municipality Desislava Zhelyazkova raised the issue of the severe shortage of nurses in Sofia’s kindergartens and nurseries, emphasizing that the scale of the problem in the capital is different and cannot be solved solely through measures such as providing housing or additional incentives. She pointed out that Sofia Municipality manages 202 kindergartens and more than 30 independent nurseries, and that ensuring the legally required number of nurses in nursery groups has created serious difficulties for years.

Zhelyazkova noted that Sofia cannot compete with hospital salaries, whether in private, municipal, or state hospitals, and questioned whether the current childcare model, focused entirely on medical care, should remain unchanged. She informed the meeting that the municipality had conducted analyses, collected opinions from universities, and was ready to provide all available materials to the Ministry of Health. As a possible solution, she proposed Sofia Municipality become a pilot municipality in which nursery groups in kindergartens would test a model involving educators who have completed mandatory healthcare and first aid training. The municipality is prepared to finance these trainings and monitor the results before any possible wider implementation.

“The issue of municipal hospitals is one of the most painful topics for all of us because, in many small and remote municipalities, the municipal hospital is the only place where people can receive timely medical assistance,” said Dr. Emil Kabaivanov, Mayor of Karlovo Municipality and member of the NAMRB Management Board.

In his remarks, Dr. Kabaivanov proposed that the Ministry of Health develop regulations requiring medical graduates trained under state-funded programs to work in municipal hospitals for three years. According to him, this would help overcome staff shortages while also giving newly graduated professionals the opportunity to obtain specialization under eased conditions. “This is not just a matter of healthcare services, but of security for people. In many regions, if the municipal hospital stops functioning, access to healthcare becomes practically impossible,” he added.

Minister Ivkova promised that the Ministry’s team would conduct a detailed analysis of the proposals and seek ways to implement them.

“Municipalities are doing everything within their power – we support residents in specialization programs, provide housing and additional incentives, finance training, but our possibilities are not unlimited,” replied Dr. Kabaivanov, emphasizing that municipalities and the Ministry are partners and allies in this process.

The Mayor of Petrich Municipality and member of the NAMRB Management Board, Dimitar Brachkov, stressed that the shortage of nurses and doctors is already seriously threatening the functioning of municipal hospitals and the child and school healthcare system. He noted that Petrich Municipality maintains a 100% municipal hospital serving around 110,000 residents across four municipalities, and despite significant local government efforts to stimulate, attract, and retain personnel – through financial support, accommodation, and other social benefits – the staffing deficit continues to deepen.

Brachkov pointed out that private hospitals often attract specialists with higher salaries, undermining municipal efforts. He also raised the issue of the lack of applicants for nursing programs, citing the example of the Southwestern University, where enrollment quotas remain unfilled. According to him, the state must find a mechanism for effectively integrating trained healthcare assistants into the system, as they are currently underutilized. He further noted that current regulations create situations in which many nurses prefer working in kindergartens and nurseries over hospital settings, and warned that without more decisive measures, the system risks losing the necessary medical staff.

Ivo Dimov proposed that the Ministry of Health hold a special meeting with the Association of Municipal Hospitals in Bulgaria (AMHB), as hospital managements are best positioned to specifically outline the problems within the system. He emphasized concerns related to negotiations on the National Framework Contract and the insufficient pricing of clinical pathways, which, according to hospital directors, no longer cover the real operating costs of healthcare facilities. Hospitals expect a substantial update of clinical pathway values – by 25% – in line with economic conditions and rising maintenance and staffing costs.

Dimov also raised the issue of the high operational requirements imposed on municipal hospitals, which healthcare facilities increasingly struggle to meet due to staff shortages. He drew particular attention to the lack of medical standards in key specialties such as obstetrics and gynecology, anesthesiology, intensive care, and cardiology, which, according to him, creates serious contradictions with clinical pathway algorithms and leads to practical difficulties in hospital operations.

The Mayor of Dimitrovgrad also highlighted the problem of delayed emergency medical care modernization projects. He gave the example of the project for a new emergency medical center in Dimitrovgrad, for which the municipality had provided the required land years ago and fulfilled its commitments, but there is still no clarity regarding the project’s progress and implementation. Similar problems exist in other municipalities, jeopardizing important investments in healthcare infrastructure and access to emergency care.

Dimov further emphasized that financial support for remote municipal hospitals must be maintained and expanded, as without this assistance many healthcare facilities will not be able to function sustainably. He noted that municipalities invest significant funds in renovations, equipment, housing, and incentives for medical professionals, yet staff shortages remain the most serious challenge facing municipal healthcare.

The Mayor of Razgrad Municipality and member of the NAMRB Management Board, Dobrin Dobrev, stressed the need to create a three-year National Program for Mosquito Population Control funded through the central budget. He emphasized that the current model, under which municipalities annually organize procedures, contract activities, and seek funding, creates a serious lack of predictability and often leads to delays in treatments when mosquito populations are already actively developing.

According to him, the problem is especially severe in areas near rivers, wetlands, and floodplains and cannot be addressed independently by individual municipalities, as mosquito populations do not follow administrative boundaries. Dobrev called for a clear coordination mechanism between the state and municipalities to ensure planning, financing, monitoring, risk zone assessment and mapping, as well as the possibility of framework agreements with a longer-term horizon. In his view, such a program would enable more effective and sustainable control of activities of public health importance and provide better protection for the population.

Minister of Health Katya Ivkova responded that many of the issues raised have accumulated over the years and cannot be resolved simultaneously, but emphasized the Ministry’s readiness for active dialogue with NAMRB and municipalities and stated that she expects concrete solution proposals from local authorities.

Regarding the National Framework Contract, she explained that discussions are yet to begin, as the new Ministry leadership has only recently taken office and changes in the composition of the National Health Insurance Fund Supervisory Board are forthcoming.

In response to concerns about municipal hospitals and staffing shortages, Minister Ivkova acknowledged the seriousness of the situation and stressed that the state must find a mechanism to guarantee access to healthcare services in all regions of the country. She also pointed to the need to review some of the requirements and algorithms under which healthcare institutions operate so that the system reflects the real situation regarding staff shortages.

On the issue of nurses and healthcare assistants, the Minister stated that the Ministry is already holding discussions with professional organizations and universities and is seeking options for broader use of healthcare assistants’ capacities. She commented that the problem is especially severe in child and school healthcare, while in some regions there are not even candidates for healthcare specializations. According to her, the issue requires coordinated action between the Ministry of Health, the Ministry of Education, and local authorities.

Regarding emergency medical care projects, Ivkova explained that delays have accumulated over the years due to land-related problems, court procedures, appeals, and rising construction costs. She noted that some projects had been transferred between different programming periods, and that the Ministry is currently working to complete the remaining facilities and seeking solutions to secure the necessary funding.

The Minister supported the need for better coordination on mosquito population control and emphasized the issue’s serious public health significance. She noted that mosquito treatment activities had been one of the key crisis topics the Ministry had addressed so far and acknowledged that the lack of predictability and coordination among institutions and municipalities creates difficulties in organizing these activities.

She stated that mosquito treatments in some of the most affected regions would begin by the end of the week, with the Ministry coordinating actions with the competent institutions. According to her, the issue requires rapid response due to the growing risk to the population in certain regions, and therefore immediate on-site actions are being undertaken in parallel with discussions on a long-term mechanism.