By Elena Dimitrova and Florina Cicșa

In March 2023, a remarkable cross-border rescue operation highlighted the evolving state of air medical services in Eastern Europe. A 7-year-old Romanian girl, severely injured while skiing in the Bulgarian resort town of Bansko, required urgent medical attention. Initially treated at a hospital in Sofia, her condition remained critical. Faced with limited options, Romania’s SMURD (“Mobile Emergency Service for Reanimation and Extrication”) decided to intervene. A SMURD helicopter was dispatched to Bulgaria and successfully airlifted the child from Sofia to the Children’s Emergency Hospital in Bucharest, where she could receive specialized care.

This operation highlighted the stark differences in air ambulance capabilities between Romania and Bulgaria. While Romania boasts a highly developed air ambulance system, Bulgaria has struggled with providing reliable air medical services. The absence of medical helicopters in Bulgaria until recently stems from the sale of the country’s only air ambulances in 2019 after Heli Air, a private company, failed to receive governmental support. As a result, Bulgaria was the only country in the European Union without medical helicopters for four years, highlighting a critical gap in emergency medical services.

How Romania Built a Successful Air Ambulance Service

Originally established in 2003 and later updated and modernized, Romania’s air ambulance system has become a vital part of its emergency medical infrastructure. The system’s success is largely attributed to strategic investments, interagency coordination between health and interior ministries, and EU funding. The system operates under the Department for Emergency Situations (DSU), which governs SMURD. Since its establishment, SMURD has managed to establish a fleet of nine helicopters and two airplanes, including advanced EC-135 helicopters and Black Hawks. These are equipped with cutting-edge medical technology, enabling them to provide life-saving interventions, particularly in hard-to-reach areas where ground ambulances might struggle. The Black Hawk helicopters, with their double transport capacity, can carry two critically ill patients at once and are also capable of multi-role operations, including firefighting and maritime rescues.

Romania’s air ambulance service covers both urban and rural areas, with 10 aeromedical bases ensuring nationwide reach. The system’s flexibility allows for the redeployment of resources, ensuring rapid responses in remote locations. Specialized pilots and medical teams are well-trained to handle various medical emergencies, including neonatal transport with specialized incubators. EU funding has played a crucial role in maintaining the system’s low operational costs, which are far lower than private air ambulance services.

This system has helped save a lot of lives. For example, in 2013, there were a total of 1,851 primary and secondary missions, while the number doubled in 2016, resulting in 3,660 missions across the country.  

Despite its advancements, Romania’s air ambulance system faces challenges due to weather conditions, particularly in mountainous regions. However, the DSU continues to improve its fleet and services with further investments and plans to expand the capacity of the service. “All these institutions work under the umbrella of the Department for Emergency Situations… to intervene as quickly as possible and to save as many lives as possible,” says Bogdan Toma, a DSU spokesperson. The goal is to continually increase intervention capacity and renew equipment where necessary. This ensures that Romania can provide fast and efficient medical care in emergencies, not only saving lives but also reducing the financial burden of privatized services.

Across the Danube: It’s Not Just about Helicopters

Bulgaria, on the other hand, has faced significant delays in establishing a fully functional air ambulance system. The lack of medical helicopters has been a serious issue, especially in remote areas where ground transport is difficult. 

Journalist Olya Stoyanova, who has followed the issue for five years, highlights the bureaucratic deadlock in establishing an Air Medical Emergency Center:

“There was a big debate over whether it should be an independent structure, fall under a ministry, or be part of emergency teams. But with constant government changes, no one was willing to take responsibility. Councils were formed, but if everything stays at a bureaucratic level, nothing will ever happen.”

Bulgaria’s challenges go beyond resources — the real issue is the lack of a coherent strategy. “It’s not just about transport or centers; it’s about leadership. A functional system isn’t built on helicopters or airplanes alone — it requires a well-structured plan. Without that, all we have are vehicles, not a solution,” says Stoyanova.

After years of setbacks, Bulgaria took a significant step forward in 2023 by reaching an agreement to purchase air ambulances from the Italian company Leonardo. The first out of eight helicopters arrived in Bulgaria in February 2024, and while two more were expected by the end of the year, delays in the global supply chain have pushed back the arrival of the remaining helicopters. The second helicopter for providing emergency medical assistance by air landed in Bulgaria only in February this year. It is already positioned at an air base in Sliven, a town in southeast Bulgaria. The base meets all regulatory requirements and even has sufficient space to accommodate two helicopters, ensuring the necessary conditions for their safe operation and maintenance.

However, it is still unclear when Bulgaria will receive its remaining helicopters. The purchase order for the helicopters provides a permissible delay period of 60 days. After that, sanctions are imposed for each subsequent day’s deviation from the deadline and the Italian company might face a sanction of a total of 500,000 BGN (250,000 euros). Once fully operational, these helicopters will cover Bulgaria’s entire territory, including areas that were previously difficult to reach by air. 

Dr. Vera Ivanova, who participated in Bulgaria’s first air ambulance mission in June 2024, stresses the need for more helicopters, especially for nighttime coverage.

“With only one helicopter [last summer], covering the entire country is challenging. Everyone wants this to happen quickly, but there’s an inevitable waiting period. Once the remaining helicopters arrive — bringing the total to eight — full national coverage will be possible. After technical inspections, each helicopter will be ready to respond rapidly within its designated area.”

The new helicopters feature advanced navigation systems and state-of-the-art medical equipment, specially adapted for air rescue. “The equipment is top-tier. We had to add some consumables and stock the medical backpacks, but overall, everything is tailored for air transport.” These additions are expected to dramatically improve response times, particularly for people involved in accidents and critically ill patients.

“Once the full fleet is operational, emergency response will be far more efficient,” Dr. Ivanova concludes. She says that helicopter space is limited, and the high altitude has negative effects on patients’ bodies. The priority is to stabilize patients on the ground to minimize interventions during flight.

Currently, Bulgaria has six air ambulance bases in Sofia, Plovdiv, Sliven, Targovishte, Montana, and Dolna Mitropolia. The government has approved helipad construction in 20 hospitals, with three licensed facilities and three more in progress. Additionally, pilots are highly trained and can land anywhere with a 30-meter, obstacle-free radius.

Currently, Bulgaria’s air ambulance service is technically equipped for night operations, but Bulgaria Heli Med Service has yet to begin nighttime missions. Preparations are underway, including securing special night vision goggles from the Italian company Leonardo, according to the Ministry of Transport.

Despite progress, challenges remain. Stoyanova acknowledges the establishment of an Air Medical Emergency Center (AMEC) as a positive step but stresses the need for better coordination:

“Different units, like the Mountain Rescue Service, should be integrated into the system.”

In the meantime, political leaders have called for stronger coordination between the Ministry of Healthcare and other institutions.

The 2023 cross-border rescue operation in which a Romanian SMURD helicopter took part underlined how crucial a well-functioning air ambulance system is in saving lives, especially during crossborder emergencies. 

Bulgaria’s air ambulance system is still in its early stages, but collaboration among emergency teams, doctors, and hospitals shows promise. Dr. Vera Ivanova remains optimistic, emphasizing that while challenges persist, enthusiasm and cooperation are driving progress.

“This is entirely new for the country, and we expected far more coordination issues. While some details still need refining, the Emergency Service centers, doctors, and hospitals are working with incredible dedication. Everyone is fully engaged and eager to help, which gives me great hope for the future,” she shares.

This story is part of the Beyond Borders project, organized by the Association of European Journalists in Bulgaria in partnership with Bucharest-based Romanian publication Gen Revista. The initiative is co-funded by the European Union. Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or the European Education and Culture Executive Agency. Neither the European Union nor the granting authority can be held responsible for them.