Drug makers, a patients' group and experts say the health insurance fund's drug budget should grow next year by the same share as drug use.

Drug use is expected to be almost 14% higher this year than last year. The National Health Insurance Fund (NHIF) will pay 67% of drug costs. The rest, about a third of the budget, will come from the companies themselves.

Deyan Denev, director of the Association of Research-Based Pharmaceutical Manufacturers in Bulgaria (ARPharM), said: "Our minimum request is that if consumption is expected to rise by a certain percentage, the budget should rise by the same percentage." He said this year's rise can be used to forecast next year's. The budget must also count the shortfall that will fall on the companies, and their share should not grow, he said.

The need for modern treatment is growing faster than the budget, and every year the industry covers the gap, Denev said. He thinks the risks are very serious if the companies' share keeps rising. He wants the fund to track spending from the start and correct it in good time.

Denev cannot say whether the companies will take on their share. Without clarity on what exactly falls to them, both the contracts with the NHIF and the collection of rebates are at risk. Rebates are a way to share the burden, but they do not replace state money, he said. In Denev's view, the NHIF, whose patients make up a quarter of the population, matters most for people who cannot pay for costly therapy themselves.

The sum the companies pay back to the fund as rebates and compensation grows every year. Economist Arkadi Sharkov showed that it was €209m in 2022, €317m in 2023, €409m in 2024 and €450m in 2025. More than €500m is expected for 2026.

The mandatory rebate to the fund is now at least 10% and up to 33%, said Petar Petrov, an expert on legal and regulatory issues. For 54% of the new therapies available in the EU, the Bulgarian market stays out of reach, because companies would lose money. Petrov said that in recent years only the drugs on the Positive Drug List, whose price the fund partly covers, have not gone up in price. He thinks companies may keep pulling drugs from the market because of current legal rules.

For rheumatology therapies, the NHIF pays 75% and the companies cover the other 25%. It has been this way for 16 years. Boryana Boteva, chair of the Association for the Development of Bulgarian Healthcare, said: "We have signals that the companies are stopping covering this difference." If that happens, patients will have to pay about €150 a month extra.

New therapies let patients live relatively well, stop them becoming disabled and lead to fewer hospital stays, Boteva said. She wants next year's budget to guarantee access to treatment, including innovative drugs.

Bulgaria has one of the highest VAT rates on drugs, Sharkov said, and this puts an extra burden on both people and companies.