Demographic trends in Europe
Ageing is the major issue facing healthcare systems. About one-third of Europe’s population will be aged 60 or over in 2025, and more than 30% of Europeans will be aged 65 or more in 2050, with a particularly rapid increase in those aged 80 years and older. One of the most recent studies on demographics in the EU25 showed that the elderly aged 80+ represent 4% of the total population. The corresponding number will grow to 6.7% in 2025, and to approximately 11% in 2050.
The number of people aged 65–79 years has increased significantly since 2000 and will do so until around 2050. The demographic effect of the postwar baby boom will start to decrease around 2030 and is expected to disappear no earlier than the middle of the century (see Figure 1). The EU population is expected to grow just slightly until 2025, before starting to drop in 2030. This trend is even greater when only the total working-age population (15–64 years) is considered.
Expenditure in healthcare
Health financing is a critical component of health systems. Figure 2 presents the World Health Organisation (WHO) data on public expenditure. It comprises the direct outlays earmarked for the enhancement of the health status of the population and/or the distribution of medical care goods and services in the population by the following financing agents: central/federal, state/provincial/regional and local/municipal authorities; extra budgetary agencies; and social security schemes.
The evolution of public health expenditure on total health expenditure in the last four years (2000–04) shows that for the most part public expenditure increased. The most remarkable expenditure increase was in the UK and Ireland (+6%) and in Lithuania (+5.3%). There was also a significant increase, about +3%, in Italy, France, Switzerland, Latvia and Cyprus. While some countries, such as Germany, have reduced their health expenditure (–3%). Almost all Eastern Europe countries follow the same decreasing trend: Poland (–1.4%), Bulgaria (–1.8%), Czech Republic (–1.3%) and Romania (–1.2%). There are also examples of stability in expenditure: Finland and Sweden had the same expenditure rate in 2000 and 2004. Figure 3 presents the growth of health expenditure per capita in several European countries. The comparison is made using the amount of money spent for each citizen, expressed in euros and adjusted for purchasing power parity (PPP). In 2004 (last year available) the expenditure per capita varied from €570 (Slovak Republic) to €3,763 (Luxembourg).
In the nine years from 1995 to 2004, health expenditure has increased in all countries, with a percentage varying from +32% (Germany) to +150% (Luxembourg). Four groups could be differentiated: countries with an increase of less than 50%, including Germany (+32%), Austria (+40%) and the Slovak Republic (+42%); countries with an increase ranging between 50% and 70%, including the Czech Republic (+51%), Italy, France, Finland and Denmark (+56%), Switzerland (+58%), Sweden (+63%), Portugal (+65%), Belgium and the Netherlands (+68%); countries with an increase ranging between 70% and 100%, including Greece (+73%), Spain (+76%), the United Kingdom (+84%), Poland (+90%) and Hungary (+93%) and countries with an increase of more than 100%, Ireland (+113%) and Luxembourg (+150%).
Looking at the per-capita expenditure for 2004, Eastern European countries have the lowest expenditure in healthcare. But at the same time, some of them have significantly increased this amount in the last decade. Poland and Hungary, for instance, have a per-capita health expenditure of €591 and €971, respectively. This is a small amount compared with the average expenditure of the other European countries (€1,760 per capita), but it will grow faster than in other countries. In the 10 years from 1995 to 2004, the per-capita health expenditure in Poland and Hungary rose by more than 90%.
Human resources for health
The availability and composition of human resources for health is an important indicator of the strength of the health system. Although there is no consensus about the optimal level of health workers for a given population, there is ample evidence that the number and quality of workers are positively associated with immunisation coverage, outreach of primary care, and infant, child and maternal survival.
Figure 4 shows a comparison of the number of doctors in European countries, calculated as density per 1,000 inhabitants. The number of physicians, as calculated in the statistics published by the WHO, includes generalists and specialists. The average value, for the 29 considered countries (EU27 + Norway and Switzerland), is 3.32 doctors per 1,000 inhabitants. This means that there are nine countries (Hungary, France, Germany, Austria, Portugal, the Czech Republic, Bulgaria, Switzerland and Lithuania) that have a value bigger than the average but smaller than four, and four countries (Italy, Greece, Estonia, Belgium) who count more than four doctors per 1,000 inhabitants.The smallest number of physicians per 1,000 people is Romania, with a density of 1.9, while Belgium has the highest value: 4.49 physicians per 1,000 inhabitants.
Figure 5 concerns nurse density per 1,000 inhabitants. The data provided by WHO in this case includes professional nurses, auxiliary nurses, enrolled nurses and other nurses, such as dental and primary care nurses. It is quite difficult to make a comparative analysis on nurse numbers because of the significant differences between countries: the average value is 8.22 nurses per 1,000 people, but there is a range of values between 3.75 (Bulgaria) and 15.2 (Ireland). This large difference could be partly explained by a different way of organising work. Just eight countries have a density of more than 10 nurses per 1,000 inhabitants, and they are located, with the exception of Switzerland (10.75), in the northern part of the continent: Sweden (10.24), Denmark (10.36), the UK (12.12), the Netherlands (13.73), Finland (14.33), Norway (14.84) and Ireland (15.2).
Core health indicators: number of beds
Hospital bed numbers provide information on healthcare capacities: for example, on the maximum number of patients who can be treated by hospitals. The definition of “acute care” beds may vary from one country to another. Cross-country variations should therefore be interpreted with caution.
Eurostat defines hospital acute care beds as those available for curative care. These beds are a subgroup of total hospital beds, defined as all hospital beds that are regularly maintained and staffed and immediately available for the care of admitted patients. Eurostat figures cover both occupied and unoccupied beds. Hospitals are defined according to the classification of healthcare providers of the System of Health Accounts (SHA), and all public and private hospitals should be covered.
The trend in European countries represented in Figure 6 shows a reduction in acute care beds. Within the five years between 1997 and 2003 – the last year available – average bed reduction totalled about 10.5%. The most important decrease happened in Italy: from 521.8 to 352.9 (–32.4 %) per 100,000 inhabitants. Three other countries have reduced their number of acute care beds by a percentage higher than 20%: Estonia (–25.9%), Lithuania (–21.8%) and Switzerland (–20.9%). The UK (–1.3%) and Greece (–1.5%) had the lowest reductions.