Data from the Health for All Database provides the most up‑to‑date picture of the status of European hospital healthcare
Pascal Garel
Chief Executive
Isabella Notarangelo
Health Economist
HOPE, the European Hospital and Healthcare Federation
For several years, hospitals have been required to act more efficiently and to increase productivity. Increased performance is indeed visible. Yet, today healthcare systems are facing conflicting trends: short and long term impacts of an economic and financial crisis; increasing demand of an ever-expanding and ageing population; increasing request and availability of technological innovations.
To adapt to this situation, the role of hospitals is further evolving. Most health systems have already moved from a traditional hospital-centric and doctor-centric pattern of care to integrated models in which hospitals work closely with primary care, community care and home-care.
The figures given in the present document are providing the most updated comparative picture of the situation of healthcare and hospitals, compared to the situation at the beginning of the 2000s. They aim to increase awareness on what has changed in hospital capacity and more generally in secondary care provision within European Union member states, generating questions, stimulating debate, and in this way fostering information exchange and knowledge sharing.
The sources of data and figures are the Health For All Database (WHO/Europe, European HFA-DB, November 2015) and the European Database on Human and Technical Resources for Health (WHO/Europe, HlthRes-DB, November 2015) of the World Health Organisation.
All European Union member states are considered, plus Switzerland and Serbia (as HOPE has members in both countries). Whenever considered appropriate two groups have been differentiated and compared: EU15, for the countries that joined the EU before 2004 (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden and United Kingdom) and EU13, for the countries that joined the EU after 2004 (Bulgaria, Cyprus, Czech Republic, Croatia, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia and Slovenia).
The considered trends normally refer to the years 2000-2013. When data on 2013 are not available, or they have not been gathered for a sufficient number of countries, the closest year is considered. Some figures are disputed for not being precise enough but at least they give a good indication of the diversity.
Financial resources for healthcare
From 2000 to 2013, the total health expenditure estimated by WHO expressed in purchasing power parity (PPP$) per capita increased on average by 84% in the EU, with effects on inpatient care, out of pocket payments and pharmaceutical expenditures. These three figures are characterized by a growing and positive trend in the considered years.
The amount of total health expenditure per capita in 2013 was 3,379 PPP$ in the EU, with wide variations around this average value: 3,871 PPP$ in EU15 and 1,538 PPP$ in EU13. Compared to 2000, the total health expenditure per capita in 2013 had increased in all European countries. In most of them it has more than doubled, but major increases can be highlighted in Romania (299%), Slovakia (255%) and Bulgaria (215%), where it has tripled or more than tripled.
CHART 1: Health expenditure in PPP$ per capita, share of public and private: year 2013
Public sector health expenditure includes outlays for health maintenance, restoration or enhancement paid by government entities, such as the Ministry of Health, other ministries and parastatal organizations, or by social security agencies. It includes transfer payments to households to offset medical care costs and extra-budgetary funds to finance health. The revenue base of these entities may comprise multiple sources, including external funds.
CHART 2: Public sector health expenditure as percentage of total government expenditure in EU and in some illustrative countries: trend 2000-2013
In 2013, the percentage of public sector health expenditure to the total health expenditure was higher than 70% in most countries, with the exception of Cyprus, Bulgaria, Latvia, Hungary, Portugal, Malta, Lithuania and Ireland and outside the EU, Serbia and Switzerland.
Between 2000 and 2013, the public health expenditure in PPP$ per capita more than doubled in many EU13 countries such as Cyprus, Poland, Slovakia, the three Baltic countries, Bulgaria and Romania and also Netherlands, which belongs to EU15. In Serbia and Switzerland the variation in these years was around 126%. The public health expenditure increase was of 67% from 2000 to 2008 and 11% from 2008 to 2013. This difference is of course due to the financial and economic crisis.
The chart number 2 shows the last-thirteen year trend concerning the share of government expenditure on health. It presents the aggregated data concerning the EU, EU15 and EU13 and the figures of the four countries having the higher and the lower values in the year 2013, Switzerland included.
CHART 3: Comparison between the variation in the total health expenditure and the variation in the private households’ out-of-pocket payment on health: years 2000-2013
In 2013, the percentages of government expenditure devoted to health differed by 4 percentage points between EU15 (16.0%) and EU13 (11.8%); Switzerland shows a percentage of 22.08%, higher but also growing faster compared to the EU member states.
The trends illustrated in the chart 2 are generally positive between 2000 and 2006 with an average increase of percentage of government outlays devoted to health by 0.2 p.p. per year. Yet, from 2006 onwards, this way of development slacked off in many countries. The reasons can be found in the beginning of economic difficulties or in the shift of interest and priorities to other sectors.
Private households’ out-of-pocket payment on health are the direct outlays of households, including gratuities and payments in-kind made to health practitioners and suppliers of pharmaceuticals, therapeutic appliances, and other goods and services. They include household payments to public services, non-profit institutions or non-governmental organisations, non-reimbursable cost sharing, deductibles, co-payments and fee-for service.
In 2013, the private contribution to healthcare spending was around 14.2% in EU15 and 23.1% in EU13. It was higher than 30% in Malta, Lithuania, Latvia, Serbia, Bulgaria and Cyprus and lower than 10% only in Netherlands, France and United Kingdom. Between 2000 and 2013 the percentage of private households’ out-of-pocket payment to total health expenditure has steadily declined in the majority of European countries.
It lessened by 1.0 p.p. in the EU, 1.1 p.p. in EU15 and by 1.3 p.p. in EU13. The most relevant rates of reduction were registered in Switzerland (from 33.0% to 25.9%), Poland (from 30.0% to 22.8%), Latvia (from 44.1% to 36.5%), Greece (from 34.4% to 26.4%) and Cyprus (from 55.9% to 46.4%). Nonetheless, the total out-of-pocket payments in PPP$ per capita continued to increase, since the total health expenditure did.
Chart 3 illustrates the trend 2000-2013 of both the total health expenditure per capita and the private households’ out-of-pocket payments on health. These values present a correlation (R² = 0.659) showing that there is dependence between the two indicators.
The chart highlights the fast growth of both expenses in most countries of EU13 (graphically this phenomenon corresponds to the fact that these countries are located in the upper-right part of the graph) and a low increase of out-of pocket payment in some countries despite an average increase in total health spending of about 76% in EU15.
A third of health payments finances running expenses (excluding investments and capital outlays) of inpatient institutions for acute, chronic and convalescent care. The funds allocated to outpatient institutions or outpatient hospitals are excluded from this computation because they are included in the ambulatory care expenses. This separation is sometimes not statistically possible for some countries; hence a quote of overlap must always be assumed.
In 2011, expenditure on inpatient care represented on average 33% of overall healthcare spending, ranging respectively from 19.8% and 21.0% in Portugal and Slovakia, to 45.2% in Switzerland and about 46.0% in Italy and Netherlands. In all countries even if a part of the total health expenditure is always funded by private insurances and out-of-pocket payments, almost the entire amount of inpatient health expenditure is publicly financed.
Last data available on expenditure on inpatient care PPP$ per capita refers to year 2011 and is available for 64% of EU countries, Switzerland included. For those countries, the total expenditure on inpatient care (PPP$ per capita) follows, on average, a growing positive trend. The exception is represented by Greece where data available shows that this indicator varies negatively (-20.0%).
CHART 4: Expenditure on inpatient care as percentage of total health expenditure, values inPPP$ per capita: year 2011
Pharmaceutical expenditure includes the consumption of pharmaceutical products supplied on prescriptions and obtained for self-medication (often referred to as over-the-counter products), as well as pharmaceuticals consumed in hospitals.
In 2011, 16.5% of total health spending is devoted to pharmaceuticals. The highest rates were registered in Hungary (33.4%), Serbia (31.3%), Slovakia (27.4%) and Greece (26.9%); the lowest rates in Denmark (6.8%), Netherlands and Switzerland (9.4%).
Between 2000 and 2011 the percentage of pharmaceutical expenditure on total health expenditure has generally declined in all of Europe. In 2011, the total pharmaceutical expenditure was encompassed between 280 PPP$ per capita in Estonia and 673 PPP$ per capita in Greece. At least half of it was held by the public sector in all countries except Italy (45.3%), Serbia (44.7%), Latvia (40.8%), Poland (39.4%), Lithuania (34.3%), and Malta (25.4%). The highest values in 2011 were Netherlands and Ireland (around 78.0%), Germany (75.6%), Greece (74.0%) and Spain (71.0%). In 2011 65.2% of total pharmaceutical expenditure is held by the public sector and it was encompassed between 136 PPP$ per capita in Estonia and 493 PPP$ per capita in Ireland.
The chart 5 explores the relationship between the trend of the total and the public pharmaceutical expenditure between 2000 and 2011. In this period of time the average increase in the total pharmaceutical expenditure was by 55.6%; the average increase in public pharmaceutical expenditure was by 60.2%. In a group of outlier countries encompassing Estonia, Greece, Ireland and Slovakia both the public and the total spending more than doubled. Only in Denmark, Italy, Luxembourg, and Portugal the rates of growth of total spending were lower than 50%.
CHART 5: Comparison between the variation in the total pharmaceutical expenditure and the variation in the public pharmaceutical expenditure: years 2000-2011
In Europe, both the total pharmaceutical expenditure and the public pharmaceutical expenditure PPP$ per capita increased from 2000 to 2009 and decreased from 2009 to 2011. In almost all the member states, the total pharmaceutical expenditure decreased more slowly than the public pharmaceutical expenditure. This suggests that a progressively larger part of the total pharmaceutical expenditure pertains to the private sector. This shift may also indicate that the “willingness to pay” and the consumption of pharmaceuticals by private owners are increasing.
CHART 6: Number of hospitals in 2013 and number of hospitals closed (opened) since 2000
Hospital capacity and delivery of care
In the last thirteen years healthcare reforms implemented all over Europe aimed at rationalizing the use and provision of hospital care, improving its quality and appropriateness, and reducing its costs. The number of hospital facilities as well as the number of hospital beds dropped off. But these reforms also resulted in a broad reduction of acute care admissions and length of stay, as well as in improvements in the occupancy rate of acute care beds.
CHART 7: Number of hospitals beds in 2013 and number of beds lifted (added) since 2000
During these years almost all European countries made changes in their hospital provision patterns, major efforts were addressed to delivering better services, increasing quality, improving efficiency and productivity. The streamlining of care delivery started from a sharp reduction in the size of secondary care institutions and moved towards more integrated and efficient patterns of care, which might in the future result in the complete overcoming of the hospital-centric model of care.
This was possible thanks to a package of financial and organizational measures addressed to improve coordination and integration between the different levels of care, increase the use of day-hospital and day-surgery and introduce new and more efficient methodologies of hospital financing in order to incentivize appropriateness (e.g. the replacement of daily payments – known to encourage longer hospitalization – by prospective payment).
In more or less all European countries these policies led to changes in the management of patients within hospitals and offered a possibility for reducing the number of acute care hospital beds. Only the bed occupancy rates, registered more disparate trends across Europe, depending also from the demographic and epidemiological structure of population and from the specific organization of local, social and healthcare systems, i.e. the structure of primary care, the presence and the efficiency of a gate-keeping system, the modality of access to secondary care, availability of home care and development of community care.
CHART 8: Number of hospital beds per 100,000 inhabitants in 2013 and number (and percentage) of beds per 100,000 lifted (or added) since 2000
In 2013 there were on average 2.8 hospitals for 100,000 inhabitants, ranging from 1.4 in Slovenia to 5.3 in France. The only European member state excluded from this range is Cyprus, where the value is around 9.5. Moreover, there were on average 530 hospital beds every 100,000 inhabitants, ranging from 259 in Sweden to 828 in Germany.
Between 2000 and 2013 little changes in the number of hospitals were registered in Slovakia (-4), Hungary (-2), Portugal (+1), Slovenia and Serbia (+2).
CHART 9: Percentage of private inpatient hospital beds: years 2000, 2004, 2008, 2013
In the same period, the total number of hospital beds per 100,000 inhabitants decreased by 17.5%. The only countertrend was registered in Greece, whose hospital beds per 100,000 inhabitants increased by 0.9%, which means 4 new beds every 100,000 inhabitants.
In several countries, the decrease in the total number of beds was accompanied by a slight increase in the number of private inpatient beds, which are inpatient beds owned by not-for-profit and for-profit private institutions. But the share of private hospital beds – where figures are available – was still quite low in most countries, with percentages higher than 30% only in Germany (59.3%), Cyprus (48.0%), France (37.8%), Spain (31.3%) and Austria (30.5%).
Between 2000 and 2013 the number of acute hospitals decreased significantly all over Europe. 317 acute care hospitals were closed in France, 311 in Germany, 148 in Italy and 114 in Switzerland.
CHART 10: Number of acute care hospital beds per 100,000 inhabitants in 2013 and number (and percentage) of acute care beds per 100,000 lifted (or added) since 2000
The rate of acute care hospital beds for 100,000 inhabitants in 2013 in Europe was 356. The highest figures were observable in Austria (535), Germany (534), Lithuania (530) and Bulgaria (524); the lowest figures in Sweden (194), Ireland (211), Spain and United Kingdom (228).
CHART 11: Comparison between rate of admision/discharge per 100 and average length of stay: year 2013
CHART 12: Bed occupancy rate for acute care hospitals: last year available
CHART 13: Rate of nurses per physician: years 2000, 2006, 2013
Between 2000 and 2013, the number of acute care hospital beds per 100,000 populations registered an average reduction by 19.8% in the EU, 19.0% in the EU15 and 20.9% in the EU13. The most significant decreases were in Latvia (-42.7%), Estonia (-38.0%), Italy and Malta (-32.0%) and Hungary (-30.5%). The only exceptions were Greece and Netherlands whose value increased respectively of 6.5% and 8.9%
The most relevant bed reductions, according to the last available data corresponding to year 2007, happened in the surgical and in the medical groups of specialties, which together represent far more than half of acute care beds. The average reduction was around 11% in the surgical specialties and 9% in the medical ones. However it was particularly high – encompassed between -20% and -40% – in the three Baltic countries and in Hungary.
The number of acute care admissions involves the entire pathway of hospitalization of a patient, who normally stays in hospital for at least 24 hours and then is discharged, returning home, being transferred to another facility or dying. Last data available for this figure refers to 2013. The rates of acute care hospital admissions in the European countries were quite dissimilar, ranging from 7.8% in Cyprus to 24.9% in Austria.
The average length of stay measures the total number of occupied hospital bed-days, divided by the total number of admissions or discharges. In 2013, the average length of stay in acute care hospitals ranged from 5.5 bed-days in Estonia to 7.7 bed-days in Germany.
Between 2000 and 2013 almost all countries stabilized their rate of admissions for all hospitals. On average this figure decreased of 0.2 p.p. (from 17.6% to 17.8%). Many of them were also able to reduce the length of stay in acute care hospitals. Indeed, the EU average improved, decreasing from 7.6 bed-days in 2000 to 6.3 bed-days in 2013. In EU15 the reduction was equal to the EU average while in EU13 the figure improved by 1.2 bed-days (from 7.6 to 6.4).
CHART 14: Number of physicians per 100,000 inhabitants and share of physicians working in hospitals: year 2o13
The link between the rate of admissions and the length of stay can be a very sensitive issue for hospitals, since it is commonly acknowledged that too short length of stay may increase the risk of re-admissions with a consequent waste of resources both for the hospital and for the patients and their careers. At the same time, staying too long in a hospital may indicate inappropriate settlements of patients, causing similar waste of resources as described above.
The chart 11 compares the rate of hospital admissions and the average length of stay in 2013. The average European figures indicate a mean rate of admissions by 17.6% and a mean length of stay of 8.2 days for all hospitals. The foremost variations between countries concern the admissions ranging from 7.8 in Cyprus to 30.6 in Bulgaria. A cluster of countries mainly encompassing EU13, present a number of admissions per 100 higher than the EU average (17.6). The smallest countries seem to be more successful in finding a good balance between these two indicators.
The bed occupancy rate represents the average number of days when hospital beds are occupied during the whole year and generally mirrors how intensively hospital capacity is used.
CHART 15: Number of practising nurses per 100,000 inhabitants: years 2000-2013
Between 2000 and 2013 there were not consistent trends in Europe, the average rate of acute bed occupancy in EU decreased by 1.0 percentage point, the other values were encompassed between +9.3 p.p. and +2.0 p.p. respectively in Ireland and Italy and -12.6 p.p. and -2.4 p.p. in Croatia and Austria. In Netherlands, the decrease in p.p. was about 20.1. These large variations are usually due to changes in the number of admissions, average length of stay and the extent to which alternatives to full hospitalization have been developed in each country.
Healthcare and hospital workforce
In 2013, the share of employment in the human health and social work sector on total employment in the 28 European member states is on average 10.7%, according to the European Commission supplement to the quarterly review on “Health and social services from an employment and economic perspective” (December, 2014). Unlike in the total economy, the number of workers in this sector had been steadily growing, and showed an increase even during the crisis years.
Furthermore, the health and social services sector, composed of human health, residential care and social work, has an important economic weight as it generates around 7.0% of the total economic output in the EU28 and appears to have suffered from the crisis.
The review underlines also that the health and social services sector is facing several challenges due to the fact that the workforce is ageing faster than in other sectors. Indeed, the vast majority of the people working in human health and social sector belong to the age group 25-49 years, while the share of people above 50 years increased from approximately 27% to 32% between 2008 and 2013 in EU28. Moreover, there are large imbalances in skills levels and working patterns and recruitment and retention are conditioned by demanding working conditions.
The financial constraints, are leading in most European countries to a decrease in the resources available for healthcare professionals, reducing the possibilities of hiring new staff. Additionally, several countries, especially in central and Eastern Europe, are experiencing migrations of their healthcare workforce.
CHART 16: Number of physicians graduated per 100,000 inhabitants: years 2000-2013
These trends are likely to have major impacts on the hospital sector, since inpatient care, alone, absorbs about a third of the healthcare resources and hospital sector gives work to more than half of active physicians. In 2013, the total hospital employment, per 100,000 inhabitants was 1,519 people in EU28, while in EU15 and EU13 this value was respectively 1,600 and 1,006. European countries, European Organizations and EU institutions are discussing possible impacts and achievable solutions to these issues.
Interestingly, several countries are shifting competences from doctors to nurses, creating new educational pathways and bachelor degrees addressed to nurses. In many cases nurses and general practitioners acquire new skills and competences relieving the burden of hospital care by enforcing primary care institutions and community services.
In 2013, EU15 had around 351 practicing physicians and 922 practicing nurses per 100,000 inhabitants and EU13 had 277 physicians and 588 nurses per 100,000 inhabitants. Almost all the EU13 member states had a share of practicing physicians lower than the EU average (334), with the only exceptions of Malta (346), Czech Republic (369), Bulgaria (398) and Lithuania (428). The share of practicing nurses per 100,000 in EU is on average of about 808. In the majority of the countries, which belong to EU13, this value is lower while the highest rates are reached in Luxembourg (1,193), Germany (1,296), Finland (1,412), Denmark (1,631) and Switzerland (1,739).
Between 2000 and 2013, the number of practicing physicians and nurses per 100,000 inhabitants increased respectively by 14% and 11% in EU28.
These figures seem generally to provide evidence of the policies implemented, or at least the trends for the management of healthcare professionals, especially concerning the allocation of resources and responsibilities between doctors and nurses. In EU the average rate of nurses per doctor is about 2.2 points. In 2013 the highest values are in Luxembourg and Switzerland (4.4), Germany (3.3), Slovenia (3.2), France and United Kingdom (3.1). In these countries there is a high shift of competencies from doctors to nurses. Conversely, countries where the values are lower are: Bulgaria (1.2), Spain (1.4) and Portugal (1.5). In Latvia, Cyprus, Austria and Italy the rate of nurses per doctor is equal to 1.6.
CHART 17: Number of nurses graduated per 100,000 inhabitants
In 2013, doctors working in hospital (full or part time) were around 50% to 60% of the total, with the highest rates registered in France (82.0%) and in Denmark (73.7%). On the other side, the lowest values regard Belgium (24.8) and Cyprus (28.7). Even if complete data for nurses are not available for many countries, figures suggest that in 2013 nurses working in hospital (full or part time) were on average 64.0%, this value being encompassed between 41.9% in Ireland and the totality of nurses in Austria and in Greece.
Relevant variations on the share of doctors working in hospital did not happen between 2000 and 2013, except in Portugal, Greece and Finland where the figure registered a significant reduction (respectively -13.4, -9.3 and -7.2), and in Malta (+15.5), Lithuania (+13.0) and Hungary (+12.4) where, on the contrary, there was a considerable increase.
In 2013, about 11.8 physicians and 41.4 nurses graduated every 100,000 inhabitants. However, the values across countries were quite different. The number of physicians graduated per 100,000 inhabitants ranged from 9.3 in France to 20.3 in Malta. The number of nurses graduated per 100,000 inhabitants ranged from 4.2 in Bulgaria to 96.1 in Romania.
Compared to 2000, the average number of physicians graduated in the EU per 100,000 inhabitants increased by 23.5%., while the number of nurses graduated per 100,000 inhabitants increased by 47.4%, with a rate particularly high in EU13 where this figure is 68.1% in average. In EU15 the increase rate is lower than in the EU and equal to 41.5%. The increase in the number of physicians graduated per 100,000 was very high in the three Baltic countries, Portugal and Slovenia. The number of nurses graduated grew especially in Poland, Latvia and Italy. These rates mirror the introduction and extension of the university-level education for nurses.
