Scientific Online Resource System

Health Economics and Management

The right to choose health insurer: A comparative review of the EU Member States’ experiences

Alexander Popov, Kristian Kaludov, Mehnur Salieva, Antoniya Dimova


Introduction: The monopoly status of the National Health Insurance Fund in Bulgaria is considered to be a major problem of the healthcare system in the country. The absence of a right by the citizens to choose a fund for social health insurance (SHI) is perceived as a weakness of the system itself. Taking this into account, all major political parties prioritize the demonopolisation of the NHIF. The aim of this study is to address the question whether the absence of a free choice of a SHI fund could be a shortcoming of the healthcare system.
Material and methods: A comparative analysis of the SHI systems across Europe has been performed. Based on information from the European Observatory on Health Systems and Policies, countries are classified into two groups: 1. countries with an absence of a free choice of a SHI fund, and 2. countries where people are free to choose the insurer. Data on countries’ population, health expenditure, and citizens satisfaction with the health systems is extracted from the Eurostat Database and the Health Consumer Powerhouse index for 2017.
Results: Sixteen EU countries have a SHI system. Citizens have no right to choose a SHI fund in 11 of them (group 1). Eight of the group 1 countries and one of the group 2 countries have a population under 10 million. In 2015, health expenditure per capita varied between 865 PPP€ (in Romania) and 4 131 PPP€ (in France) in the 1st group and between 1612 PPP€ (Slovakia) and 4 113 PPP€ (Germany) in the second group. SHI expenditure as a share of total health expenditure varies widely within the two groups as well. In both groups, there are highly ranged health systems according to the European Health Consumer Index for 2017 with a total score above 700.
Conclusion: The free choice of a SHI fund does not seem to influence either the health expenditure size and structure or citizens satisfaction with the health system. The monopoly status of the NHIF in Bulgaria cannot be perceived as an immediate and ultimate shortcoming of the healthcare system and the search for the causes of ineffectiveness and poor performance of the system should take a more complex approach.


health insurance; choice of insurer; EU; Bulgaria

Full Text


Berthet F. (2015). HiT in Brief. Luxemburg: 2015, Health Systems in Transition, European Observatory on Health Systems

Eurostat (2018). Eurostat [online database]. Brussels, European Commission (

Health Consumer Powerhouse (2018). Health Consumer Index 2017 (

HSPM (2018). Country profiles [web page] for Austria, Belgium, Croatia, Czech Republic, Estonia, France, Germany, Hungary, Lithuania, Netherlands, Poland, Romania, Slovenia, Switzerland (

Smatana M, Pažitný P, Kandilaki D, Laktišová M, Sedláková D, Palušková M, van Ginneken E, Spranger A (2016). Slovakia: Health system review. Health Systems in Transition, 2016; 18(6):1–210.

WHO (2018). Global Health Expenditure Database [online database]. Last update: February 12, 2018 (Available at:

WHO Regional Office for Europe (2018). European Health Information Gateway / Health for All explorer [online database].Copenhagen, WHO Regional Office for Europe (

Димова А., М. Попов, М. Рохова (2007). Здравната реформа в България: необходимост, развитие, резултати, перспективи. Институт Отворено общество, София

Костадинова С. (2007). Грешният пример против демонополизацията на НЗОК, Преглед на стопанската политика, 2.03.2007, Институт за пазарна икономика, София, (

МС (2017), Програма за управление на Правителството на Република България за периода 2017-2021 г. Решение № 447 на Министерския съвет от 09.08.2017 г. (



Font Size