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1st June 2023
The health status in Germany has improved over the last two decades, and life expectancy remains above the EU average despite the temporary reduction registered in 2020 that was caused by the Covid-19 pandemic.
Infection and death rates from Covid-19 in 2020 were lower in Germany than in most other EU countries. When measured as a share of GDP, health spending in Germany is the highest in Europe. The health system offers a generous benefits package, high levels of service provision and universal access to relatively high-quality and effective care. The Covid-19 pandemic revealed the challenges faced by federal systems in coordinating and managing such outbreaks.
In 2020, Germany registered a life expectancy of 81.1 years – six months above the EU average but still somewhat lower than in EU countries with the highest levels. The Covid-19 pandemic had less of an impact on life expectancy in Germany than in the EU as a whole, having fallen by 2.5 months in 2020 compared to an average of just over eight months across the EU. The leading causes of death in Germany in 2019 were ischaemic heart disease, stroke and lung cancer.
Around one in five adults smokes on a daily basis in Germany. While smoking rates have been declining, the growing popularity of e-cigarettes, particularly among young people, is a cause for concern. Adult and adolescent obesity rates are growing, and alcohol consumption among adults and 15-year-olds is considerably higher than the EU average.
In 2019, Germany spent €4,505 per capita on health – the highest among EU countries, and 28% more than the average (€3,523). Germany also spends a greater proportion of its GDP on health (11.7%) than any other EU country. The majority of health spending comes from public sources; out-of-pocket payments amount to only 12.7%, which is well below most other EU countries.
Mortality from preventable causes is lower in Germany than in the EU as a whole, reflecting the country’s effective public health and primary care system. Germany also has lower rates of death from treatable causes, owing to good access to effective treatments.
Access to care is generally good in Germany. Historically low rates for unmet needs rose during the Covid-19 pandemic when many non-urgent services were cancelled or postponed. One in seven people reported that they had to forgo needed care in 2020. However, the use of teleconsultations increased during the pandemic.
Despite well prepared health infrastructure and resources, Germany scaled up testing and laboratory capacities, intensive care unit beds and the health workforce. By the end of August 2021, around 60% of the population had received two Covid-19 vaccine doses.
OECD/European Observatory on Health Systems and Policies (2021), Germany: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.
15th May 2023
A study of almost three million women found no evidence of an increased risk of menstrual changes after Covid vaccination.
Researchers suggested there was a weak association between the vaccine and menstrual disturbance or premenstrual bleeding, in a paper published in the BMJ.
The findings do not provide ‘any substantial support’ for a causal association between the Covid vaccination and healthcare contacts related to menstrual or bleeding disorders, the authors said.
Many women self-report changes to their periods after a Covid vaccine – including excessive, frequent, absent or irregular menstruation – and a link between the vaccine and menstrual disturbance has also been discussed on social media, causing global concern.
The researchers in Sweden drew on high-quality health registry data to evaluate the risks of menstrual disturbance and bleeding after the Covid vaccination in 2,946,448 women aged 12-74 from December 2020 to February 2022.
The authors, led by Rickard Ljung, professor at the Swedish Medical Products Agency, said: ‘We observed weak and inconsistent associations between SARS-CoV-2 vaccination and healthcare contacts for postmenopausal bleeding, and even less consistent for menstrual disturbance, and premenstrual bleeding.’
The healthcare contacts in the study included primary care visits, specialist outpatient visits, and days of hospital stay related to menstrual disturbance or bleeding before or after menopause.
Pfizer-BioNTech, Moderna, and Oxford-AstraZeneca vaccines were all assessed along with the dose number, whether that be unvaccinated, first, second, and third dose.
This was measured over a control period of one to seven days, followed by a second time window of eight to 90 days.
More than 88% of women received at least one Covid vaccination and over 64% of vaccinated women received three doses during the study period.
The highest risks for bleeding in post-menopausal women were seen after the third dose in the one-to-seven-day risk window (28%) and in the eight-to-90-day risk window (25%).
The analysis also suggested a 23-33% increased risk of post-menopausal bleeding after eight to 90 days, with Pfizer-BioNTech and Moderna after the third dose, but a less clear association with Oxford-AstraZeneca.
However, the study concluded that after adjusting for socioeconomic factors, previous healthcare use and specific medical conditions, this almost completely removed weak associations, suggesting a casual effect was unlikely.
A version of this story was originally published by our sister publication Pulse.
11th May 2023
A higher BMI increases the risk of hospitalisation or death following a respiratory tract infection, according to an analysis published in JAMA.
Body mass index (BMI) has a J-shaped associations with overall mortality and with many cause-specific deaths. In addition, during the Covid-19 pandemic it became clear that being overweight increases the risk of Covid-19-related hospitalisations. Nevertheless, whether or not there is a relationship between BMI and other respiratory infections, viral or otherwise, is less clear.
In the current study, researchers used data from the UK Biobank, to explore the relationship between body mass index and the risk of hospitalisation for, or death from, respiratory infections. The team focused not only on Covid-19 but both upper and lower respiratory tract infections (RTIs). Researchers excluded participants with a chronic respiratory disease or previous hospitalisations for infectious respiratory diseases. Modelling assessed the association between BMI categories of 14 – 24.9, 25 – 29.9 (the reference point), 30-34.9, and 35-60.
Data was available for 476, 176 participants (median age = 58 years, 54% female) and the mean BMI was 27.4. Participant follow-up occurred over an average of 11.8 years.
During follow-up, 20,302 individuals were hospitalised or died of severe infectious respiratory diseases. For Covid-19, the fully adjusted hazard ratios (HRs) ranged from 0.66 for those with a BMI of 14 – 24.9, to 2.27 (95% CI 1.73 – 2.97) for the highest category (e.g., 35 – 60). For a lower RTI, HRs ranged from 0.94 to 1.68 among those in the highest BMI category. A similar trend was seen for upper RTIs.
The authors suggest the implementation of approaches to reduce obesity and target vaccinations for respiratory infections in those with an elevated BMI.
9th May 2023
The global health emergency posed by Covid-19 is over, the World Health Organization (WHO) has declared, while also stressing that the disease remains a ‘global health threat’.
For over a year, the Covid-19 pandemic had been ‘on a downward trend’, due to population immunity increasing from vaccination and infection, mortality decreasing and the pressure on health systems easing, said Dr Tedros Adhanom Ghebreyesus, director-general of the WHO.
WHO and the Emergency Committee, convened under the International Health Regulations, ‘have been analysing the data carefully and considering when the time would be right to lower the level of alarm’ over the last twelve months.
Based on their recommendations, Dr Tedros declared Covid-19 over as a global health emergency on 5 Mya 2023, making the statement ‘with great hope’ he said.
‘That does not mean Covid-19 is over as a global health threat’, he stressed. Indeed, one person dies from Covid-19 every three minutes, thousands of people around the world are currently in intensive care units with the condition and there are ‘millions more’ suffering the effects of long-Covid.
‘This virus is here to stay. It is still killing, and it’s still changing. The risk remains of new variants emerging that cause new surges in cases and deaths,’ Dr Tedros said, warning countries to be complacent. ‘The worst thing any country could do now’ would be ‘to use this news as a reason to let down its guard, to dismantle the systems it has built, or to send the message to its people that Covid-19 is nothing to worry about’.
Instead, he advised countries to transition from ’emergency mode to managing Covid-19 alongside other infectious diseases’,’ added Dr Tedros’, evidence of which has been seen recently with WHO’s recent pulse survey revealing a move towards restoring essential health services.
Dr Tedros also celebrated the efforts of healthcare workers in helping to control the virus.
‘We have arrived at this moment thanks to the incredible skill and selfless dedication of health and care workers,’ he said. ‘The suffering we have endured, the painful lessons we have learned, the investments we have made and the capacities we have built must not go to waste’.
‘We owe it to those we have lost to leverage those investments; to build on those capacities; to learn those lessons, and to transform that suffering into meaningful and lasting change,’ he added, urging ‘a commitment to future generations that we will not go back to the old cycle of panic and neglect that left our world vulnerable’.
A version of this story was originally published by our sister publication The Pharmacist.
2nd May 2023
Health systems are showing the first major signs of recovery from the Covid-19 pandemic, but further investment in recovery and resilience is needed, according to a new report from the World Health Organization (WHO).
By early 2023, fewer countries reported intentionally scaling back access across all service delivery platforms and essential public health functions since the last round of reporting. In fact, disruptions in the delivery of routine health services were found to have declined on average from 56% in July-September 2021 to 23% in November 2022-January 2023.
The WHO interim report on the fourth round of the global pulse survey also revealed the number of countries reporting disruption to their national supply chain system reduced from nearly half (29 of 59 responding countries) to around a quarter (18 of 66 responding countries) within the last year.
Despite this improvement in Covid-19 recovery, the report found that demand and supply disruptions persist, with increasing service backlogs – most frequently in screening, diagnosis and treatment of noncommunicable diseases – being prevalent across all countries responding to the survey.
“It is welcome news that health systems in the majority of countries are starting to restore essential health services for millions of people who missed them during the Covid-19 pandemic,” said Dr Rudi Eggers, WHO Director for Integrated Health Services. “But we need to ensure that all countries continue to close this gap to recover health services and apply lessons learnt to build more prepared and resilient health systems for the future.”
Concerns remain over the delayed recovery of essential health service delivery as this “may have even greater adverse health effects at population and individual level than the pandemic itself, especially among vulnerable populations”, the WHO concluded.
To this end, three quarters of countries reported additional funding allocation towards longer term system recovery, resilience and preparedness.
28th April 2023
Dr Urmas Sule, HOPE president, details how Estonia has weathered the significant challenges of 2022 and his hopes and expectations for 2023.
In 2022, we moved from Covid-19 to an energy crisis and the uncertainty of war. Unfortunately, Covid is still very much present. Managing one crisis after another, and sometimes doing it simultaneously, proves a challenge for maintaining a reasonable balance of healthcare services for Covid and non-Covid patients. In my opinion, we have succeeded in guarding the patients’ interests and safety the best way.
During these difficult times, we saw how important it was to have smooth cooperation between hospitals and healthcare providers. An effective distribution of tasks and responsibilities was developed to protect patients’ interests in the best possible way.
We as hospital managers cooperate well with the Health Board, the Health Insurance Fund and the Government of Estonia. Continuous negotiations with the Government and the Health Insurance Fund about adequate financing of services and support for the health sector were necessary and proved very fruitful.
Our partnership with the Estonian Medical Association, the Medical Faculty of the University and the Health Care Colleges has been a big help in involving medical and nursing students.
Our main focus for 2022 was, and will always be, to protect our healthcare workers from burnout. This is not an easy task and needs good cooperation between all partners.
Similar to other European countries, Estonia also faces the problem of a shortage of healthcare workers. Healthcare specialists are working for multiple employers. This is good for knowledge exchange, but is difficult to organise in a pandemic situation. Shortages have been a problem in Estonia for a long time, not just during Covid. The pandemic intensified the problem. Ensuring a reasonable division of labour and responsibilities between hospitals and other healthcare institutions has been a challenge.
But there are also other barriers, too. Political priorities have shifted from solving the healthcare crisis to an energy crisis and the effects of war. The primary focus has been improving readiness for emergencies in all areas. Helping Ukrainian refugees, providing them with social security and healthcare services is one of the important and ongoing challenges.
The Estonian Government created a new crisis staff structure during Covid. This structure was adapted for the healthcare sector together with the Estonian Hospitals Association network. We have collaborated with the Estonian Health Insurance Fund to guarantee the best possible availability of healthcare services to all patients. This has been possible due to the prudent and flexible planning and financing of services.
To motivate employees, we have negotiated collective agreements in two-year increments. This has been a good opportunity to hear the needs and expectations of healthcare workers so we can do our best to try to meet those expectations and improve working conditions. Negotiations for the coming years are currently underway, and we will make all efforts to find a balanced agreement and retain the effective and trusting relationships among our social partners.
The Health Insurance Fund measures the need for health services to lessen the treatment deficit. In collaboration, we have negotiated and agreed on the measures to reduce treatment deficits for non-Covid patients. We planned and introduced new services to prepare for Ukrainian refugees entering the healthcare system. But the biggest challenge for hospitals is the rapid and continuous rising costs of energy and other services.
We have monitored hospitals’ workloads and cooperated to ensure best use of all resources – especially the healthcare workforce – to create a flexible system that is prepared for new challenges.
We have seen a rapid growth of the development and use of e-services and remote services and consultations in the healthcare sector in Estonia. There has been great development across many specialities – psychiatry, for example – during the pandemic. This has been possible due to the collaboration between hospitals, other healthcare providers and the Health Insurance Fund.
Because of the health crisis, we have increased infection control capacity and knowledge, not only in the healthcare sector, but also in society. A nationwide vaccination campaign has also alleviated the effects of Covid and the burden on the healthcare system.
We are negotiating the 2023/24 collective agreement with the Medical Association, Nurses Association and other trade unions. It is a challenge to achieve a balance between reasonable salaries and general pricing principles that include all input prices and guarantee adequate availability of patient services.
At the same time, our healthcare system has to achieve the best possible flexibility to be prepared for any possible crises. This seems like an endless and boundless task!
Life expectancy in Belgium remains slightly above the EU average, but it temporarily fell sharply in 2020 because of deaths due to Covid-19.
While the Belgian health system provides good access to high-quality care, the Covid-19 pandemic highlighted important challenges with prevention and public health, the health workforce and quality of care in long-term care facilities for older people. The pandemic stimulated many innovative practices in Belgium that could be expanded to build a more resilient healthcare system.
Life expectancy in Belgium increased more than the EU average between 2010 and 2019, but fell by more than a year in 2020 because of deaths due to Covid-19. About 60% of the Covid-19 deaths in 2020 were among residents in long-term care facilities. As in many other countries, the mental health of many young people and adults in Belgium deteriorated greatly during the pandemic, with reports of anxiety and depression reaching much higher levels than in previous years.
Risk factors for health are major drivers of ill health and mortality in Belgium. While tobacco consumption has substantially decreased over the past two decades, 15% of adults were daily smokers in 2018. Nearly 30% of adults reported regular heavy alcohol consumption in 2018, a rate well above the EU average. About 16% of adults were obese in 2018, close to the EU average, but up from 12% in 2001. Overweight and obesity among 15-year-old adolescents have also increased to 17% in 2018, up from 11% in 2002.
Health spending per capita increased slowly between 2008 and 2019 and remains higher than the EU average. In 2019, health spending accounted for 10.7% of GDP, up from 9.6% in 2008, and also a higher share than the current EU average (9.9%). Public spending accounted for 77% of overall health spending – slightly less than the EU average of 80%.
Avoidable mortality was slightly lower than the EU average before the pandemic, but higher than in many other western EU countries. This suggests that more could be done to save the lives of people through health promotion and a reduction of risk factors and through better healthcare.
Although access to healthcare in Belgium is generally good, the Covid-19 pandemic significantly affected access to care in 2020: 22% reported forgone care during the first 12 months of the pandemic, which is close to the EU average of 21%. Growing use of teleconsultations helped maintain access to care during the pandemic.
Belgium was among the EU countries hardest hit by the Covid-19 pandemic in numbers of cases and deaths relative to its population size, particularly during the first wave. Belgium accelerated its vaccination campaign in the first half of 2021. By the end of August 2021, 70% of the population had received two doses (or equivalent) of a Covid-19 vaccine.
OECD/European Observatory on Health Systems and Policies (2021), Belgium: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.
Life expectancy in Austria is higher than the EU average, but fell sharply in 2020 due to Covid-19 deaths.
While the Austrian health system generally provides good access to high-quality care, the Covid-19 pandemic underscored some structural issues, including the need to pursue reforms to overcome fragmentation and strengthen primary care.
A strong digital infrastructure offers Austria the potential to build a more integrated and resilient health system.
Although life expectancy in Austria in 2020 was more than half a year higher than the EU average, it fell by 0.7 year compared with 2019 because of the Covid-19 pandemic. Even before the pandemic, gains in life expectancy in Austria had slowed considerably between 2010 and 2019.
About 40% of all deaths in Austria in 2019 can be attributed to behavioural risk factors. Tobacco consumption among adults has fallen but remains slightly higher than the EU average. Alcohol consumption among adults in Austria is the second highest in the EU. Heavy alcohol consumption among adolescents is also higher than the EU average.
Spending on health per capita in Austria was the third highest in the EU in 2019. Austria spends substantially more than most countries on hospital inpatient care, while spending on prevention is lower than average. It also has relatively high numbers of physicians and hospital beds. While three quarters of all health expenditure is publicly funded, direct out-of-pocket spending by households is higher than the EU average.
Mortality from preventable and treatable causes in 2018 was lower in Austria than the EU average. Nevertheless, Austria lagged behind many other EU countries on preventable mortality, suggesting that more could be done to scale up prevention and reduce risk factors for cancer and other leading causes of death.
Access to healthcare is good in Austria, although Covid-19 created barriers to access. One in eight Austrians reported that they had forgone care during the first 12 months of the pandemic. Digital services helped to maintain access to care during the Covid-19 crisis: 35% of Austrians reported that they used teleconsultation services during the first year of the pandemic, which was slightly lower than the EU average.
Between March 2020 and August 2021, confirmed Covid-19 case numbers in Austria were similar to the EU average, although the death rate was lower. By the end August 2021, more than 60% of the population had received at least one dose of a Covid-19 vaccine, and 57% had received two doses or the equivalent. These proportions were close to the EU average.
OECD/European Observatory on Health Systems and Policies (2021), Austria: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.
HOPE and HealthPros have been collaborating with researchers from the Amsterdam University Medical Centres at the University of Amsterdam since 2020 around the subject of data sharing and exchange.
This webinar presents the results of the project. There is special emphasis on examples of how data exchange between hospitals and other healthcare organisations changed during the Covid-19 pandemic in different member states across Europe.
24th April 2023
Treatment with fluvoxamine (FA) in high-risk COVID-19 patients reduces the need for hospitalisation. This action likely arises because of an anti-inflammatory and anti-viral effect of the drug. In addition, inhaled budesonide improves the time to recovery and possibly hospital admissions or death in patients with COVID-19. As both drugs appear to be effective, whether fluvoxamine and inhaled budesonide together might offer additional benefit is unclear.
In the current trial, researchers randomised high-risk, ambulatory patients 1:1 to oral FA plus inhaled budesonide or matching placebos. Fluvoxamine 100 mg twice daily and budesonide 800 mcg twice daily were given for 10 days. The primary outcome was a composite of emergency setting retention for COVID-19 for more than 6 hours, hospitalisation, and or suspected complications due to progression of COVID-19 within 28 days of randomisation.
Fluvoxamine and Inhaled budesonide and COVID-19 outcomes
The study had 1476 participants with 738 given FA and inhaled budesonide. Symptoms were present for a median of three days before randomisation. The median age was 51 years with women accounting for 60.8% of the total. Overall, 42% of participants had received 3 doses of a COVID-19 vaccine.
The proportion of patients in an emergency setting for more than 6 hours or hospitalised due to COVID-19 was lower in the treatment group than the placebo group (relative risk, RR = 0.50, 95% CI 0.25 – 0.92). These results gave a number needed to treat of 53.
The findings suggest that oral fluvoxamine plus inhaled budesonide in high-risk outpatients with early COVID-19 reduces the incidence of severe disease requiring advanced care.
Citation
Reis G et al. Oral Fluvoxamine With Inhaled Budesonide for Treatment of Early-Onset COVID-19 : A Randomized Platform Trial. Ann Intern Med 2023
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