Regional Disparities in Cancer Mortality in Bulgaria: Socioeconomic and Healthcare Determinants

Background

The relatively low cancer mortality rates in Bulgaria compared to EU averages may conceal substantial regional inequalities and potential gaps in cancer detection, registration and access to care.

Aim

This study examines the trends in age-standardized cancer mortality (ASMR) across Bulgaria’s 28 regions and explores associations with socioeconomic and health system determinants.

Methods

ASMRs for 2018–2023 were calculated using data for the number of cancer deaths and population by gender and region, and the 2013 European Standard Population. Multivariate linear regression was used to evaluate the association between ASMR variation and GDP, poverty rate, urbanization, ethnic composition and GP density. Spatial analyses were performed using Global Moran’s I.

Results

National ASMR rose from 234.3 per 100 000 in 2018 to 246.8 in 2020, followed by a decline to 220.5 in 2021–2022 and subsequent increase to 226.1 in 2023. Substantial regional inequality persisted through the period, with a rate ratio of 2.15 (95% CI 2.11 – 2.19) between the regions with highest and lowest rates in 2023. Higher GP density (β = 20.0, p < 0.001) and urbanization (β = 101.6, p < 0.001) were associated with higher ASMR, while GDP per capita, ethnicity and poverty rate were not statistically significant. Spatial analysis showed no evidence of significant clustering (Moran’s I = −0.127, p = 0.76), indicating a fragmented pattern of regional variation.

Conclusions

Marked regional disparities in cancer mortality in Bulgaria persist, associated more strongly with healthcare access indicators than with socioeconomic deprivation. The positive association between GP density, urbanization, and mortality may reflect differential diagnostic and registration capacity rather than true underlying disease burden. The findings highlight the need to strengthen local policies, cancer diagnostic and treatment in underserved regions and improve the completeness of cancer mortality registration.

Key messages

• Cancer mortality in Bulgaria varies more than two-fold across regions, driven more by healthcare access and diagnostic capacity than by socioeconomic deprivation.

• Low national cancer mortality rate may mask underdiagnosis in low-access areas, highlighting the need to strengthen regional diagnostic capacity and GP networks.