The nursing workforce crisis in Bulgaria: Workforce imbalance , educational capacity, and urgent health policy reform

Abstract

Bulgaria faces a structural nursing workforce crisis that threatens the accessibility, safety, and continuity of health and social care. This review analyzes the scale and age structure of the nursing shortage, the imbalance between nurses and physicians, the educational pipeline, and policy options for rapid and sustainable workforce recovery. A structured narrative review and secondary analysis of official data from the Organisation for Economic Co-operation and Development (OECD), Bulgarian National Statistical Institute, Ministry of Health, Sofia Municipality, European Union legislation, professional organizations, and peer-reviewed workforce studies were conducted, using information available through 24 September 2026. In 2025, Bulgaria had 28,357 practicing nurses and 30,409 physicians under a main employment contract, corresponding to only 0.93 nurses per physician. More than 76% of nurses were aged 45 years or older and 18.4% were aged 65 years or older. OECD data show 4.4 nurses per 1,000 population in Bulgaria versus 9.1 on average across OECD countries, while the nursing graduate rate was 7.6 per 100,000 population versus 45.7 across the OECD. Increasing university admission alone cannot correct the shortage within the necessary time horizon. Bulgaria requires an integrated policy combining workforce forecasting, educational reform, student support, safe staffing, retention, skill-mix redesign, expanded nursing roles, regional incentives, and continuous outcome monitoring. A three-year educational pathway should be evaluated only as a regulated policy option that preserves European minimum training hours and competencies, not as a stand-alone solution.

Keywords: nursing workforce; nurse shortage; health policy; nursing education; workforce planning