Revista Quincenal Médicos de Soria - Colegio Oficial de Médicos de

Transcription

Revista Quincenal
Ilustre Colegio Oficial de
Médicos
de
Soria
www.comsor.es
1ª Quincena de diciembre de 2012
Edición Nº 10 · 2012
Avda. Mariano Vicén, 31, 1º piso
42003 SORIA
Teléf. 975 22 29 92 y 975 22 29 58
FAX 975 21 17 21
http://www.comsor.es
[email protected]
[email protected]
Indice de Contenidos
Edición Nº 10
1ª Quincena de diciembre de 2012
Firmas en defensa del Hospital Público de Soria . . . . . 3
Continúan las movilizaciones en Madrid . . . . . . . . . 3
Modelo de Autonomía de Gestión en Atención Primaria en
Madrid. . . . . . . . . . . . . . . . . . . . . . . . . . . 3
El Foro de la Profesión Médica exige soluciones a la
situación de Madrid y se suma a la manifestación de
febrero. . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Profesión médica y reforma sanitaria . . . . . . . . . . . 3
La OMC solicita a Echániz que rectifique . . . . . . . . . 4
Panorama de la Salud: Europa 2012. . . . . . . . . . . . 4
Boletín Europa al día Nº 380 PANORAMA DE LA SALUD:
EUROPA 2012. . . . . . . . . . . . . . . . . . . . . . . 4
Conclusiones VIH 2012 . . . . . . . . . . . . . . . . . . 4
PAIME: atención al médico enfermo. . . . . . . . . . . . 5
Propuesta de Cursos de Inglés para Médicos SpanDoc. . 5
Prueba ECOE. . . . . . . . . . . . . . . . . . . . . . . 5
EL COLEGIO INVITA A TODOS SUS COLEGIADOS A
PARTICIPAR CON SUS APORTACIONES (CIENTIFICAS,
PROFESIONALES, OPINIONES, INFORMACIONES,
NOTICIAS, ETC.) EN NUESTRA REVISTA ELECTRÓNICA
QUINCENAL.. . . . . . . . . . . . . . . . . . . . . . . . 5
Ofertas de Empleo . . . . . . . . . . . . . . . . . . . . . 5
Médico especializado en Urología pediátrica.. . . . 5
Ofertas de trabajo para MEDICO OFTALMOLOGO en
FRANCIA.. . . . . . . . . . . . . . . . . . . . . . 7
El Hospital Universitario Río Hortega de Valladolid
quiere proceder a la contratación de Médicos
Especialistas en Radiodiagnóstico con experiencia en
patología mamaria.. . . . . . . . . . . . . . . . . . 9
Nuevas Ofertas de Empleo para especialistas en
Reino Unido. . . . . . . . . . . . . . . . . . . . . 10
Oferta de trabajo en Londres . . . . . . . . . . . . . . . . . . . . 14
Oferta de trabajo en Castellón. . . . . . . . . . . . . . . . . . . 14
El Hospital Reina Sofía de Tudela (Navarra) necesita un facultativo
especialista en Ginecología y otro facultativo especialista en
Traumatología. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
OFERTA DE TRABAJO MÉDICO/A de ADECCO MEDICAL &
SCIENCE SALAMANCA,. . . . . . . . . . . . . . . . . 14
Centro de reproducción asistida ubicado en Sevilla, oferta puesto de
ginecólogo/a especialista. . . . . . . . . . . . . . . . . . . . . 15
NUEVAS OPORTUNIDADES PARA MEDICOS EN EL REINO UNIDO .
15
Ofertas de empleo de Hertfordshire Partnership NHS Foundation
Trust. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Grupo Clave Servicios Empresariales selecciona Director Médico
del Trabajo para importante empresa de ámbito nacional con sede en
Lugo.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Fundación de Hemoterapia y Hemodonación de Castilla y León
BUSCA LICENCIADOS EN MEDICINA PARA TRABAJAR EN
SEGOVIA Y PROVINCIA Y EN CASTILLA Y LEON. . . . . . . . . 16
Anexos. . . . . . . . . . . . . . . . . . . . . . . . . . 24
COMSOR.ES
Boletín Informativo
Edición Nº 10
Semana del 1ª Quincena de diciembre de 2012
Firmas en defensa del Hospital Público de Soria
La Plataforma en Defensa del Hospital Santa Bárbara de Soria, encabezada por el Colegio Oficial de Médicos de Soria, ha registrado más de
3.000 firmas en la Consejería de Sanidad de la Junta de Castilla y León para exigir a la Administración Regional que ejecute la segunda fase de
las obras del Hospital Público de Soria. Finalmente los presupuestos regionales no incluyen esta infraestructura, aunque dedican dos millones
de euros a diferentes actuaciones. Desde el COMSOR se pide la ejecución del plan completo tal y como estaba previsto.
Continúan las movilizaciones en Madrid
El conflicto entre el sector sanitario y la Comunidad de Madrid está, de momento, lejos de solucionarse. Los profesionales continúan con
diferentes movilizaciones, incluida la huelga, y la mitad de los equipos directivos de los centros de salud han firmado una carta anunciando su
dimisión si el Gobierno Regional continúa con sus planes de privatización.
http://www.elmundo.es/elmundosalud/2012/12/20/noticias/1356024882.htm
http://ccaa.elpais.com/ccaa/2012/12/20/madrid/1356012619_886592.html
http://ccaa.elpais.com/ccaa/2012/12/20/madrid/1356008417_569102.html
Modelo de Autonomía de Gestión en Atención Primaria en
Madrid
Desde los diferentes colectivos vinculados con el Sistema Nacional de Salud, incluido el Colegio de Médicos de Madrid, se ha elaborado un
estudio que analiza la situación de la sanidad madrileña y las consecuencias de las medidas anunciadas por la Administración Regional.
La Ley de Presupuestos de la Comuniad de Madrid para 2013 incluye el “Plan de Garantía de sostenibilidad del Sistema Sanitario Público”
que, entre otras medidas, contempla sacar a concurso la gestión de 27 centros de salud. Esta medida supone, en la práctica, la salida de los
trabajadores: médicos de familia, pediatras, enfermeras, matronas, administrativos y personal de apoyo.
Adjuntamos informe completo en la sección anexos.
El Foro de la Profesión Médica exige soluciones a la situación
de Madrid y se suma a la manifestación de febrero
El Foro de la Profesión Médica, en su reunión del 13 de diciembre, decidió exigir una solución inmediata a la situación actual de la sanidad en
la Comunidad de Madrid. Desde el Foro califican la respuesta de los profesionales a las medidas adoptadas por el Gobierno de la Comunidad
como “coherente y adecuada”. Además, el colectivo reitera su apoyo a la manifestación convocada el próximo 23 de febrero en Madrid con
el objeto de; por un lado, defender a ultranza el SNS y, por otro, mostrar un rechazo unánime a las medidas indiscriminadas que afecten a la
calidad de la asistencia y a la buena praxis tanto a nivel del Estado como de las Comunidades Autónomas.
Adjuntamos comunicado en la sección anexos
Profesión médica y reforma sanitaria
La OMC ha presentado a Nuñez Feijoo, presidente de la Xunta de Galicia, un documento con diferentes propuestas para llevar a cabo la reforma
sanitaria que garantice la sostenibilidad del sistema. Acuerdo político, financiación estable, buen gobierno en el Sistema Nacional de Salud,
buena gestión en centros y servicios y un contrato social renovado con los sanitarios, son los cinco puntos clave que incluye el documento.
El texto de la OMC considera que “la respuesta sostenible y eficiente a la crisis financiera en la sanidad, exige cambios estructurales y de
estrategias” pero expone que “los recortes lineales bloquean estos cambios e imponen reducciones que no sólo afectan a lo prescindible si lo
hubiera, sino que también a lo imprescindible para mantener la calidad de los servicios sanitarios”.
Adjuntamos más información en la sección anexos.
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COMSOR.ES
Edición Nº 10
La OMC solicita a Echániz que rectifique
El secretario general de la OMC, Serafin Romero, ha solicitado al Consejero de Sanidad de Castilla la Mancha, José Ignacio Echániz, una rectificación inmediata de sus declaraciones en relación a las “peonadas” en las que pone de manifiesto graves acusaciones contra los profesionales
médicos a los que acusa de “realizar intervenciones innecesarias” a cambios de emolumentos económicos.
Adjuntamos comunicado de la OMC en la sección anexos
Panorama de la Salud: Europa 2012
La Comisión Europea y la OCDE han publicado conjuntamente un informe que recoge los indicadores clave sobre los factores determinantes
de la salud, los recursos y actividades de la asistencia sanitaria, la calidad de la atención sanitaria y el gasto y financiación de los 35 países
europeos. En general la situación ha mejorado notablemente, aunque persisten las grandes diferencias.
http://www.cmourense.org/Blog/contenido/950/PANORAMA_DE_LA_SALUD_EUROPA_2012
Boletín Europa al día Nº 380 PANORAMA DE LA SALUD:
EUROPA 2012
La Comisión Europea y la OCDE han publicado conjuntamente un informe que, bajo el título Panorama de la salud: Europa 2012, recoge los
indicadores clave sobre los factores determinantes de la salud, los recursos y actividades de la asistencia sanitaria, la calidad de la atención
sanitaria y el gasto y la financiación de la salud en 35 países europeos, que son, los 27 Estados miembros de la UE, 5 países candidatos y 3
países de la AELC/EFTA.
Entre las principales conclusiones del informe, podemos señalar las siguientes:
• En general, la situación sanitaria ha mejorado considerablemente aunque siguen existiendo grandes diferencias.
• El número de médicos y de enfermeros per cápita es más alto que nunca en la mayoría de los países, pero preocupa la escasez actual o
futura de personal.
• La esperanza de vida al nacer en los países de la UE aumentó en más de seis años entre 1980 y 2010.
• La prevalencia de enfermedades crónicas como la diabetes, el asma y la demencia es cada vez más elevada.
• La mayor parte de los países europeos ha reducido el consumo de tabaco mediante campañas de sensibilización de la opinión pública, la
prohibición de la publicidad y mayores impuestos.
• El aumento del gasto sanitario per cápita se ralentizó o incluso se detuvo en términos reales en 2010 en casi todos los países europeos,
lo que invirtió una tendencia de incremento constante.
En el presente Boletín “Europa al día” ampliamos esta información e incluimos el texto íntegro del informe del que sólo existe versión inglesa.
Conclusiones VIH 2012
Las tasas de nuevos diagnósticos en España son similares a las de otros países en Europa Occidental, aunque superiores a la media de la Unión
Europea, según se desprende del último estudio realizado. Promover el diagnóstico precoz debe ser un factor clave para controlar la epidemia
en Europa, teniendo en cuenta que el retraso en el diagnóstico sigue siendo una asignatura pendiente y sólo ha descendido entre los HSH.
Adjuntamos informe en la sección anexos.
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COMSOR.ES
Edición Nº 10
PAIME: atención al médico enfermo
El Programa de Atención Integral al médico Enfermo (PAIME) es un programa para facilitar a los médicos el acceso a una tención sanitaria
de calidad y especializada en caso de enfermedades relacionadas con trastornos psíquicos o conductas adictivas que puedan interferir en su
práctica profesional.
Teléfono de información: 628793793
Adjuntamos más información en sección anexos.
Propuesta de Cursos de Inglés para Médicos SpanDoc
Podéis ampliar la información en el enlace siguiente:
http://www.spandoc.com/colegiosmedicos.html
Prueba ECOE
Os informamos de que se ha aprobado el borrador de proyecto sobre el acceso excepcional al título de Médico Especialista en Medicina Familiar
y Comunitaria (prueba ECOE). La fecha de solicitud de la ECOE pasa del 31/1/2013 al 31/3/2013.
EL COLEGIO INVITA A TODOS SUS COLEGIADOS A
PARTICIPAR CON SUS APORTACIONES (CIENTIFICAS,
PROFESIONALES, OPINIONES, INFORMACIONES, NOTICIAS,
ETC.) EN NUESTRA REVISTA ELECTRÓNICA QUINCENAL.
¡ ANIMO ! ES VUESTRA
Ofertas de Empleo
Médico especializado en Urología pediátrica.
Responsable de dirigir y supervisar la prestación de atención de alta calidad basada en la eficacia, diagnosticar y dirigir una eficiente gestión,
en el tratamiento de todos los pacientes.
Del médico tratante se espera que sea un ejemplo de excelencia clínica dentro de su especialidad así como proporcionar liderazgo y capacitación para el personal médico junior.
Se espera que demuestren un gran interés y participación activa en la investigación.
Funciones principales:
Soportes, implementos y sigue todas las iniciativas Cliente, departamentos y divisiones políticas y procedimientos.
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COMSOR.ES
Edición Nº 10
Ayude a dirigir, ejecutar, y participar en la gestión del desempeño de la organización del sistema, incluyendo la revisión inter pares y el proceso
de revisión de la productividad y la utilización.
Revisar las actividades clínicas del personal médico junior y asumir la responsabilidad del cuidado que proporcionan.
Diagnosticar y tratar a pacientes de acuerdo con las normas establecidas del puesto.
Fomentar una cultura de mejora, aprendizaje y desarrollo continuo a través del departamento de urología.
Cumplir con todas las políticas establecidas en materia de admisión de clientes, consultas, diario del paciente, atención, procedimientos quirúrgicos, protocolos de descarga, consulta externa y seguimiento de prácticas.
Prácticas adecuadas para la utilización de los recursos del cliente.
Realizar tareas clínicas y garantizar la continuidad de la atención.
Participar en actividades de desarrollo de la investigación con un enfoque profesional y aplicarse con conformidad.
Responsabilidades específicas del trabajo:
Dirigir, evaluar y reconsiderar los pacientes hospitalizados de forma regular, con el mejor servicio posible.
Regularmente revisar los resultados de todas las investigaciones y modificar el tratamiento según sea necesario.
Servir de enlace con otras especialidades médicas y servicios de apoyo para el ingreso adicional que sea necesario.
Participar activamente en las reuniones multidisciplinarias para ayudar a planificar la atención eficaz, segura y holística para los pacientes
individuales.
Aceptar pacientes clínicamente proporcionados desde el Servicio de Urgencias, Atención Primaria, u otros departamentos, clínicas de especialidades.
Comunicar la información clínica de los pacientes a familiares del paciente o amigos (con
consentimiento del paciente) de una manera oportuna.
Mantener la confidencialidad con respecto a cualquier intercambio de información recibida
de acuerdo con la política del cliente.
Asumir el papel de embajador de la marca para el establecimiento y la promoción de una filosofía del cliente en el trato con las partes interesadas.
Organizar y llevar a cabo un programa de mejora de calidad para la división, los monitores y
Los informes sobre las iniciativas de calidad al Jefe de División.
Participar en programas para enseñar a los estudiantes, la formación de médicos y en la práctica clínica de exámenes.
Facilitar el suministro de capacitación pertinente indispensable para el personal clínico en la especialidad.
Mostrando compromiso con la Educación Médica Continua (CME)
Requisitos:
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COMSOR.ES
Edición Nº 10
El cumplimiento satisfactorio de un Consejo de Acreditación de Educación Médica para Graduados (ACGME) programa de residencia en los
Estados Unidos y la certificación por una de las especialidades médicas, juntas de la Junta Americana de Especialidades Médicas (ABMS)
El cumplimiento satisfactorio de un programa de residencia acreditado por el Colegio Real de Médicos y Cirujanos de Canadá, y la Certificación
de Especialistas por el Colegio Real de Médicos y Cirujanos de Canadá.
El cumplimiento satisfactorio de un programa de entrenamiento de residencia acreditado por una autoridad competente de un Estado miembro
de la Comunidad Europea, o certificación de especialista de acuerdo con el Consejo Directiva.
Se necesita un nivel de Inglés MUY alto.
Más información:
En Doha, la capital de Qatar, nuestro cliente es una instalación del estado que se centrará principalmente en la mujer y la salud de los niños.
Además de proporcionar servicios de clase mundial de salud, el centro también será un ambiente de aprendizaje para los estudiantes de medicina y residentes, que abarca cooperativamente la investigación nacional e internacional. La calidad de primera clase de cliente se refleja en el
diseño innovador del centro y en el uso de las más modernas tecnologías de última generación.
Beneficios:
-Ingresos libres de impuestos
-Alojamientos completamente amueblado.
-Billetes de vuelos anuales
-Cobertura médica completa
-Vacaciones anuales pagadas
-Las ofertas están supeditadas a recibir una visa de trabajo, una vez que la visa es otorgada, el
proceso para llegar hasta el país de destino y puesto de trabajo.
-Cuando se hace una oferta, el candidato seleccionado deberá suministrar la información
documentos y referencias necesarios. Este proceso puede tomar desde una semana a un mes.
equipo de on-boarding le guiará a través del
Laboratorio privado en el norte de Alemania
Para el sobresaliente laboratorio de uno de nuestros clientes, buscamos para lo antes posible, un Fachärztin/Facharzt für Laboratoriumsmedizin
El laboratorio está acreditado tanto para medicina como para forense y cuenta con los más modernos aparatos de análisis.
Las tareas a realizar entre otros serán:
La responsabilidad del análisis en el laboratorio
La validación medica
Aconsejar en el marco del diagnostico del laboratorio
Perfil:
Licenciatura en medicina
Especialidad relacionada con laboratorios
Alemán B2 mínimo
Inglés alto
ENVIAR CV en inglés y datos de contacto a [email protected] con asunto “Urología pediatrica” o “Especialista en Laboratorio”.
Ofertas de trabajo para MEDICO OFTALMOLOGO en FRANCIA.
PAGINA
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COMSOR.ES
Edición Nº 10
Anglet, 5 de diciembre de 2012
Estimados Sres.:
Somos Laborare Conseil, especializada en procesos de selección de personal sanitario para trabajar en Francia y en Holanda, en hospitales,
consultas o clínicas, según la oferta que sea difundida y el origen de la misma (a veces contrato privado y a veces en el marco de concursos
públicos ganados por nuestra empresa para contratar personal para hospitales). Actualmente realizamos nuevos procesos de selección de 1
MEDICO OFTALMOLOGO para INSTALARSE EN FRANCIA COMO ASALARIADO CON CONTRATO LABORAL FIJO.
Además de esta oferta actualmente abierta, les informamos de que regularmente contratamos MEDICOS DE CUALQUIER ESPECIALIDAD para
trabajar en Francia y en los Países Bajos (Holanda), por lo que les estaríamos muy agradecidos si realizaran la difusión general de nuestras ofertas que adjunto remitimos para que las personas interesadas pudieran ir ganando tiempo y enviar su candidatura, pues determinados puestos
de trabajo se cubren con candidaturas espontáneas inmediatamente.
Les estaríamos muy agradecidos si validaran esta información y procedieran a su difusión a través de su tablón de anuncios, o por el medio que
ustedes consideren oportuno. Si necesitaran un soporte informático de estos documentos, o cualquier información complementaria, no duden
en solicitárnoslo en el e-mail [email protected]
Les agradeceríamos también si indicaran a los interesados que las candidaturas se deben enviar al mail [email protected], lo que
facilitará su posterior tratamiento.
Para cualquier aclaración o información complementaria que puedan desear, no duden en enviar un mail a [email protected]
Sin otro más particular, reciban un cordial saludo:
Sra. Yael Brugos Miranda
[email protected] / www.laborare-conseil.com
LABORARE CONSEIL es una empresa certificada OPQCM en los campos de la selección de personal, de los recursos humanos y generalista.
ISQ-OPQCM es el único organismo profesional francés de certificación de empresas de servicios intelectuales reconocido por el Ministerio de
Economía, de Industria y de Empleo.
Laborare Conseil, especializada en la selección de personal sanitario europeo, selecciona, para un importante grupo de salud francés, a tres
horas en coche de Barcelona y tres horas y media de Irún, y una hora del aeropuerto internacional de Toulouse
1 MEDICOS OFTALMOLOGO
Motivado para INSTALARSE EN FRANCIA Y TRABAJAR EN CONSULTAS COMO ASALARIADO, a lo largo del año 2013
Se ofrece:
-Contrato fijo en régimen general de seguridad social.
-Salario mínimo garantizado durante los 3 primeros meses: 4000 € brutos al mes, pudiéndose estimar una media de salario bruto mensual de
entre 5.800 euros para principiantes y 14.500 para profesionales con experiencia confirmada y técnica avanzada.
-Horarios fijos y adaptables.
-Son organizados y coste a cargo de la empresa: material, secretaria, gestión administrativa...
-Formación sobre el idioma técnico, y colaboración posible en la enseñanza del francés, si ello es necesario y así se acuerda con el candidato.
FRANCES: no se exige por tanto hablarlo en el momento de la entrevista y selección, aunque el médico interesado deberá estudiarlo por su
cuenta y a su propio coste antes de empezar a trabajar. Además, la mutualidad podrá cofinanciar el aprendizaje de la lengua francesa del candidato, parcialmente, y según nivel inicial del candidato.
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COMSOR.ES
Edición Nº 10
-Alojamiento gratuito durante 3 meses.
-Interesantes perspectivas de evolución profesional.
Interesados contactar con Yael BRUGOS MIRANDA enviando CURRICULUM VITAE a [email protected]
Laborare Conseil, especializada en la selección de personal sanitario europeo, selecciona, para VARIOS HOSPITALES CONSULTAS Y CLINICAS sitas en varias ciudades francesas,
MEDICOS DE TODO TIPO DE ESPECIALIDADES: RADIOLOGOS, ANESTESISTAS REANIMADORES, DE URGENCIAS, ANATOMIA PATOLOGICA, MEDICINA INTERNA, DE FAMILIA, PEDIATRIA, GERIATRIA, CARDIOLOGIA… TODOS LOS PERFILES Y ESPECIALIDADES SERAN
ESTUDIADOS
Motivados para TRABAJAR EN FRANCIA O EN LOS PAISES BAJOS (HOLANDA) a lo largo del año 2013
Se ofrece:
-Contrato asalariado del sector público, del sector privado o de colaboración siendo autónomo, punto variable según la oferta.
-Retribución/facturación variable según la oferta, y según el número de pacientes que tratar (se explicarán condiciones de oferta concreta a
candidatos concretos).
-Enseñanza del lenguaje técnico.
-Francés general: poseer conocimientos de la lengua francesa previamente sería un plus, pero no es condición indispensable inicial. El candidato deberá comprometerse a estudiar el francés previamente si aún no posee un nivel adecuado.
-Alojamiento en general no gratuito (punto variable según la oferta) aunque ayudamos a encontrar el mismo.
-Interesantes perspectivas de evolución profesional.
-Puestos disponibles a lo largo de todo el año 2012 o del primer trimestre de 2013.
-Apoyo administrativo, logístico y formativo, y de material, para facilitar la instalación del nuevo dentista.
Interesados contactar con Yael BRUGOS MIRANDA indicando referencia INSTALACION EN CONSULTA enviando CURRICULUM VITAE a [email protected]
El Hospital Universitario Río Hortega de Valladolid quiere proceder a la
contratación de Médicos Especialistas en Radiodiagnóstico con experiencia en
patología mamaria.
Las personas interesadas pueden enviar su Currículo Vital a la Dirección Medica del HURH al e-mail: dirmed.
[email protected]
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COMSOR.ES
Edición Nº 10
Nuevas Ofertas de Empleo para especialistas en Reino Unido
ANESTESISTA - UK
Nº Vacantes: 1
País: Wales, UK
Salario: £36,807 - £68,638
Requerimientos mínimos:
• Anestesista con 4 años de experiencia, y al menos 2 como anestesista
• Se valora experiencia previa en NHS
• Inglés C1 o C2
CARDIÓLOGO
Nº Vacantes: 1
País: Wales, UK
Salario: £36,807 - £68,638
• Cardiólogo con 4 años de experiencia, y al menos 2 como cardiólogo
• Inglés C1 o C2
• Experiencia:
o Experiencia trabajando de forma efectiva como parte de equipo multidisciplinario
o Compromiso con trabajo en equipo y disciplinario
o Se valora experiencia como parte de equipo de dirección
o Coordinación con otras agencias u organismos
o Educación y entrenamiento de personal médico graduado y no graduado
o Se valora iniciación, progreso y cumplimentación de auditorías
o Se valora capacidad experiencia en investigación
o Se valora experiencia previa en NHS/experiencia en prácticas y sistemas de NHS
• Entendimiento de gestión de riesgo clínico y gestión general clínica
• Capacidad para tomar decisiones clínicas independientes cuando sea necesario y capacidad para buscar consejo de doctores senior
cuando sea apropiado
• Capacidad para gestionar el propio tiempo y carga de trabajo
• Experiencia en evaluación de emergencias
• Capacidad de trabajo como miembro de un equipo o de forma independiente
• Excelentes habilidades de comunicación – habilidad para tratar con tacto al paciente/relativos y personal
• Habilidad de enseñanza
• Flexible y adaptable a las demandas
• Carnet de conducir/capacidad para movilizarse
• Capacidad para hacer guardias
• Compromiso con prácticas nuevas
ESPECIALISTA URGENCIAS
Nº Vacantes: 3
País: Wales, UK
Salario: £36,807 - £68,638
• 4 años de experiencia, y al menos 2 en campo de urgencias (emergencias y accidentes)
• Inglés C1 o C2
GERIATRA
PAGINA
10
COMSOR.ES
Edición Nº 10
Nº Vacantes: 1
País: Wales, UK
Salario: £36,807 - £68,638
• Geriatra con 4 años de experiencia, y al menos 2 como geriatra
• Inglés C1 o C2
• Experiencia:
o Experiencia trabajando de forma efectiva como parte de equipo multidisciplinario
o Algo de experiencia endoscópica
o Compromiso con trabajo en equipo y disciplinario
o Se valora experiencia como parte de equipo de dirección
o Se valora iniciación, progreso y cumplimentación de auditorías
o Se valora capacidad experiencia en investigación
• Entendimiento de gestión de riesgo clínico y gestión general clínica
• Capacidad para tomar decisiones clínicas independientes cuando sea necesario y capacidad para buscar consejo de doctores senior
cuando sea apropiado
• Capacidad para gestionar el propio tiempo y carga de trabajo
• Experiencia en evaluación de emergencias
• Capacidad de trabajo como miembro de un equipo o de forma independiente
JEFE DE ANESTESIA OBSTETRICA - UK
Nº Vacantes: 2
País: Gales, UK
Salario: £74,504 - £100,466
• Anestesista con 7 años de experiencia en anestesia
• Inglés C1 o C2
• Experiencia
o Efectividad de trabajo como parte de un equipo multidisciplinario
o Se valora experiencia en equipo directivo
o Experiencia en investigaciones
o Capacidad para asesorar un funcionamiento eficiente de especialistas, capacidad de organización, gestión y priorización de la carga de
trabajo
o Iniciación, progreso y cumplimentación de auditorías
o Se valora capacidad para aplicar resultados de investigación a problemas clínicos
• Habilidades de liderazgo y trabajo en equipo
• Entendimiento de sistemas tecnológicos y de la información.
• Se valora interés en anestesia obstétrica
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11
COMSOR.ES
Edición Nº 10
• Capacidad para adquirir rol de liderazgo en el desarrollo clínico
• Se valoran otros grados/diplomas relevantes
JEFE DE ANESTESIA - UK
Nº Vacantes: 1
País: Gales, UK
Salario: £74,504 - £100,466
• Anestesista con 7 años de experiencia en anestesia
• Inglés C1 o C2
• Experiencia
trabajo
JEFE DE MEDICINA (CARDIOLOGÍA) - UK
Nº Vacantes: 1
País: Gales, UK
Salario: £74,504 - £100,466
• Cardiología con 7 años de experiencia en cardiología
• Inglés C1 o C2
• Experiencia
trabajo
PAGINA
12
COMSOR.ES
Edición Nº 10
JEFE DE MEDICINA (GERIATRÍA) - UK
Nº Vacantes: 1
País: Gales, UK
Salario: £74,504 - £100,466
• Geriatra con 7 años de experiencia en geriatría
• Inglés C1 o C2
• Experiencia
trabajo
JEFE DE RADIOLOGÍA - UK
Nº Vacantes: 3
País: Gales, UK
Salario: £74,504 - £100,466
• Radiólogo con 7 años de experiencia en radiología
• Inglés C1 o C2
PAGINA
13
COMSOR.ES
Edición Nº 10
• Experiencia
trabajo
o Se valora capacidad para ofrecer opinión clínica experta en emergencias dentro de la especialidad. Capacidad para tener responsabilidad
completa e independiente para el cuidado clínico de los pacientes. Interés en complementar a los actuales jefes
• Se valora Interés en radiología de pecho
[email protected]
Oferta de trabajo en Londres
The North West London Hospitals NHS Trust, un grupo de hospitales públicos, necesita médicos de emergencias para trabajar en Londres. Se
buscan médicos especialistas en medicina de urgencias y en curso de especialidad. El contrato sería de dos años y se requiere un nivel alto
de inglés.
La persona de contacto es Teena Ferguson.
Email: [email protected]
Teléfono: 0034664365714 o 00442088695205
Oferta de trabajo en Castellón
Se necesita un Facultativo Especialista en Urología, preferiblemente formado vía MIR, para el Hospital de Vinarós. El puesto de trabajo sería a
jornada completa, incluyendo guardias.
Email. [email protected]
Teléfono: 964477014
El Hospital Reina Sofía de Tudela (Navarra) necesita un facultativo especialista
en Ginecología y otro facultativo especialista en Traumatología.
El contrato es de seis meses con incorporación inmediata en un hospital comarcal con 168 camas. Ambos servicios los componen 11 profesionales y se realizarán guardias de presencia física y localizada.
Los interesados pueden informarse en el teléfono 848434110 o por correo electrónico: [email protected]
OFERTA DE TRABAJO MÉDICO/A de ADECCO MEDICAL & SCIENCE
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COMSOR.ES
Edición Nº 10
SALAMANCA,
Adecco Medical & Science, consultora líder especializada en la búsqueda y selección de perfiles de las áreas Sanitaria, Científica, Farmacéutica
y Preventiva, selecciona Médico/a Asistencial para la provincia de Salamanca
Se requiere:
- Licenciatura en Medicina
- Homologación y permiso de trabajo en caso de profesional extranjero
- Valorable experiencia mínima de un año.
Se ofrece:
- Compatibilidad con otro trabajo
DATOS DE CONTACTO
Interesados enviar CV a [email protected] ó [email protected] Ó bien llamar al 983 36 05 95
Centro de reproducción asistida ubicado en Sevilla, oferta puesto de
ginecólogo/a especialista
Centro de reproducción asistida ubicado en Sevilla, oferta puesto de ginecólogo/a especialista (Se requiere título de especialista vía MIR u homologado), no es necesario acreditar experiencia en clínicas/centros de fertilidad. Se oferta contrato laboral a tiempo completo o en modalidad
freelance.
Condiciones a negociar con el candidato.
Interesados enviar CV a: [email protected]
NUEVAS OPORTUNIDADES PARA MEDICOS EN EL REINO UNIDO
GlobalMediRec ofrece nuevas oportunidades para los médicos en Hospitales en el NHS (Servicio de Salud Pública) en el Reino Unido. Actualmente estamos buscando:
4 Medicos Especialistas en Geriatria
Se trata de puestos de trabajo permanentes a tiempo completo, con 1 año de contrato inicial. El sueldo es de entre £ 74.000 y £ 101000 libras al
año para las horas de trabajo no excederá de 37½ horas a la semana (+ guardias). Los Hospitales están en el norte Londres,e Manchester cerca
al aeropuerto, que es un excelente lugar para el regreso en españ para el fin de semana: iniciará vuelos directos de bajo coste a los principales
aeropuertos españolos. GlobalMediRec concertar entrevistas telefónicas, asistencia para el registro de GMC (Colegio Médicos Inglés), y toda
la logística de trasladar al Reino Unido. La asistencia de GlobalMediRec es completamente GRATIS por los medicos
Para más información, favor de enviar su Curriculum Vitae a: Emma Keeler Head of International Resourcing – GlobalMediRec emmakeeler@
globalmedirec.com +44 203 2392699 +44 7881 590203
Ofertas de empleo de Hertfordshire Partnership NHS Foundation Trust
Hertfordshire Partnership NHS Foundation Trust es una organización en constante crecimiento que busca experimentados, entusiastas, flexibles
y comprometidos doctores en un amplio rango de especialidades, dentro de las que se destacan las siguientes:
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15
COMSOR.ES
Edición Nº 10
· Psiquiatría General en Adultos y Geriátrica
· Problemas de Aprendizaje
· Forense
· Salud mental en niños y adolescentes
El rango salarial varia entre 45.000€ y 80.000€S dependiendo de la experiencia previa, mas excelentes beneficios.
El proceso de selección tendrá lugar en Valencia, España los días 13 y 14 de Julio para aquellos candidatos que hayan pasado la entrevista
previa por Skype. Para mas información acerca de las oportunidades que ofrecemos y para ser tenido en cuenta para el proceso de selección,
por favor enviar CV en ingles, formato Word, titulado “Doctor for the UK” a la siguiente dirección:
[email protected]
Carlos Perez
3 Sandyford Office Park,
Sandyford, Dublin
E-mail: [email protected]
http://bestpersonnelpt.webs.com
www.facebook.com/BESTPERSONNEL
Grupo Clave Servicios Empresariales selecciona Director Médico del Trabajo
para importante empresa de ámbito nacional con sede en Lugo.
Requisitos mínimos:
• Licenciado/a en Medicina, especialidad en Medicina del Trabajo.
• Imprescindible experiencia mínima en puesto similar de al menos 5 años.
• Disponibilidad para viajar a nivel nacional.
• Fijar residencia en Lugo.
• Trabajo en equipo y orientado a resultados.
• Organizar y dirigir un equipo de trabajo.
Funciones del puesto
•
•
•
•
•
Analizar la situación de las delegaciones nacionales a su cargo.
Supervisión, control y coordinación de la actividad desarrollada por el Área Médica de las Delegaciones.
Proponer las Acciones Correctoras necesarias para conseguir los objetivos planificados.
Realizar el seguimiento de los planes de actuación a nivel nacional.
Transmitir la política y criterios médicos de la Compañía.
Interesados/as envíen CV a las siguientes direcciones de correo electrónico:
- [email protected]
- [email protected]
Fundación de Hemoterapia y Hemodonación de Castilla y León
BUSCA LICENCIADOS EN MEDICINA PARA TRABAJAR EN SEGOVIA Y
PROVINCIA Y EN CASTILLA Y LEON
PAGINA
16
COMSOR.ES
Edición Nº 10
OFRECEMOS:
• Trabajo como Médico de Colectas para sustituciones de vacaciones de verano y fechas puntuales en Segovia y/o provincia. Y en varias
provincias de la Comunidad de Castilla y León.
• Retribución muy interesante.
• Formación a cargo del Centro de Hemoterapia y Hemodonación de Castilla y León.
• Se valorará carné de conducir B y disponibilidad de vehículo propio.
INTERESADOS
• Ponerse en contacto con el Centro de Hemoterapia y Hemodonación de Castilla y León. Paseo Filipinos s/n. 47007 Valladolid.
• Tfno. 983 10 16 80 de 9:00 a 14:00 de lunes a viernes
• E-mail: [email protected]
PAGINA
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COMSOR.ES
Edición Nº 10
PAGINA
18
COMSOR.ES
Edición Nº 10
PAGINA
19
COMSOR.ES
Edición Nº 10
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20
COMSOR.ES
Edición Nº 10
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21
COMSOR.ES
Edición Nº 10
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COMSOR.ES
Edición Nº 10
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COMSOR.ES
Edición Nº 10
Anexos
A continuación figuran los documentos anexos a los artículos e informaciones del boletín.
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24
Foto portada por Valentín Guisande:
Nacimiento (detalle)
Los pastores de Belén (detalle)
Adoración de los Magos (detalle)
Iglesia de Santo Domingo. Siglo XII (Soria)
PROFESIÓN MÉDICA Y REFORMA SANITARIA
Propuestas para una acción inmediata
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1
Diciembre, 2012
PRESENTACION
La elaboración del texto que hoy se presenta en Galicia se llevó a cabo a
lo largo de los meses de mayo y junio de este mismo año 2012. El documento
responde a una petición del Presidente de la Xunta de Galicia D. Alberto Núñez
Feijoo al Presidente del Consejo General de Colegios Médicos de España
(CGCOM) D. Juan José Rodriguez Sendin, interesado aquel en conocer el punto
de vista de la profesión médica en relación a las tensiones por las que está
atravesando la sanidad pública en nuestro país. El Presidente del CGCOM
encargó a su vez la redacción a diez profesionales, la mayor parte de los cuales
no ostenta representación institucional alguna y muchos de ellos con actividad
clínica asistencial.
En el estado actual de la crisis por la que atraviesa nuestro país seis meses
es mucho tiempo. Lo que significa que desde la conclusión de la versión
definitiva
hasta
el
momento
presente
se
han
sucedido
importantes
acontecimientos: han aparecido nuevas normas con sus correspondientes
desarrollos, se han revisado a la baja los presupuestos, modificado algunas
condiciones laborales, salarios incluidos, y la sociedad y los representantes
profesionales se han pronunciado en uno u otro sentido. Y es previsible que se
sucedan medidas en relación con los medicamentos, tanto las que se refieren a
una mayor convergencia con otros estados miembros en la participación del
usuario como al énfasis en los análisis de coste-efectividad sobre nuevos
fármacos. Propuestas legítimas, pero que deben argumentarse y explicarse. Lo
que, por cierto, no se ha hecho con la reciente e improvisada formulación de
unas reformas discutibles en algunas Comunidades Autónomas y que están
recibiendo una fuerte contestación profesional.
También hay que decir que se ha maniobrado con acierto para acotar los
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como la Xunta de Galicia, pactando con los colectivos afectados, han conseguido
2
efectos negativos de algunas medidas. En este sentido, algunas administraciones
minimizar el impacto de la retirada de la asistencia a personas en riesgo de
exclusión. Con ello se demuestra que incluso en momentos de extraordinaria
dificultad, los principios –y consensos- básicos sobre los que se asienta nuestro
sistema sanitario no sólo deben sino que pueden ser preservados.
En el documento se mencionan “líneas rojas” que no deben sobrepasarse
cuando el gasto sanitario se vuelva a revisar anualmente, si no se quiere
provocar un deterioro irreversible en la calidad de los servicios prestados. Con
independencia de la dificultad de fijar con absoluta exactitud una cifra concreta y
que ha de basarse en estimaciones, todo el mundo concuerda en que lo que es
exigible en primer lugar es la revisión de las actividades inadecuadas y/o
innecesarias. Sin embargo, los trabajos para identificar las mismas se están
llevando a cabo con tal premiosidad que se corre un serio riesgo de seguir
podando por lo más fácil y no por lo menos importante.
La respuesta sostenible y eficiente a la crisis financiera en la sanidad, exige
cambios estructurales y de estrategias; pero los recortes lineales bloquean estos
cambios e imponen reducciones que no sólo afectan a lo prescindible si lo
hubiera, sino que también a lo imprescindible para mantener la calidad de los
servicios sanitarios.
La única forma de hacer economías selectivas que promuevan la
sostenibilidad interna del Sistema Nacional de Salud es revitalizando la alianza
con los profesionales y utilizando instrumentos de gestión y gobierno clínico.
Pero el ambiente creado por muchas políticas extemporáneas cuando no hostiles,
no es el más favorable para establecer estas vías fluidas de diálogo. No obstante
lo anterior, la posición de la Organización Médica Colegial es inequívoca; toca
hablar y buscar soluciones reales asi como comprometerse en su puesta en
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3
práctica.
En la base de todas las propuestas efectuadas late la exigencia de dar un
protagonismo efectivo y de mayor alcance a la profesión médica. El liderazgo
médico, una forma mayor de protagonismo, por así decirlo, no se traduce en la
demanda de generar mayor confusión y ruido a través de la multiplicación de
órganos asesores. De hecho, la mayor parte de órganos asesores en los que
intervienen los médicos apenas son escuchados y, como mucho, reciben algunas
explicaciones. Por otro lado, como se suele decir coloquialmente, ni están todos
los que son ni son todos los que están. Conviene estudiar las fórmulas más
eficaces para que ese liderazgo de la profesión médica exista realmente y no
provoque desconfianza ni impida la fluidez en la toma de decisiones sino todo lo
contrario. La profesión apuesta por esta vía.
Este trabajo se presenta en Galicia, y no es por casualidad. Es de justicia
señalar el esfuerzo que está llevando a cabo la Xunta de Galicia para, de manera
respetuosa con las decisiones que se toman en otros niveles de la administración,
provocar la menor distorsión posible en el funcionamiento de los servicios
sanitarios. Últimamente, en Galicia se han llevado a cabo valiosas iniciativas que
van desde la introducción de mayor racionalidad en el uso de los medicamentos,
algo en que los médicos aún pueden seguir colaborando, hasta un mayor
esfuerzo por adoptar un enfoque más sensible con las necesidades de la
profesión. Pasando por la expansión en el uso de los sistemas de información
con el objetivo –y de momento incluso con algunos resultados- de incrementar la
eficiencia del sistema sanitario. Mejorar la eficiencia es garantizar la sostenibilidad
en la aciaga situación por la que atravesamos. La profesión médica considera una
oportunidad contar con la interlocución de un Gobierno sensible y confía en la
generalización de esta actitud.
Por último cabe decir que se trata, como no podría ser de otra manera, de
un documento crítico. Quizá la mayor recriminación se hace a la incapacidad de
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pública como terreno propicio para ponerse zancadillas. Por eso se solicita
4
los representantes políticos a corregir su tendencia a usar –y abusar- de la sanidad
reiteradamente, aunque con menguada esperanza, que se rectifique y se pacte lo
fundamental. No es obligatorio estar de acuerdo con todo lo que se dice pero
queremos resaltar que se trata de un texto redactado de buena fe y con espíritu
constructivo. Las administraciones públicas no deben esperar de sus interlocutores
sociales –y, desde luego, no de la profesión médica- manifestaciones acríticas de
mera adhesión inquebrantable a políticas partidarias. Sería una pérdida de
tiempo para quien las formulara y aún sería peor para quien las recibiera, que de
esa forma se privaría de una oportunidad de calibrar correctamente sus
decisiones de cara al interés general. En el diseño de políticas públicas, la
participación implica tensiones, con frecuencia salpicadas de errores y
contradicciones, pero lo que ha animado al Consejo General de Colegios
Oficiales de Médicos a manifestar su deseo de colaboración es su irrenunciable
voluntad de hacerse escuchar y al tiempo de ser útil y responsable.
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5
Juan Jose Rodriguez Sendin
Presidente
Consejo General de Colegios Oficiales de Médicos
PROFESIÓN MÉDICA Y REFORMA SANITARIA
Propuestas para una acción inmediata
Capítulo I
EL SNS: FINANCIACIÓN Y SOSTENIBILIDAD
Capítulo II
LA NECESIDAD DE UN GRAN ACUERDO POLÍTICO
Capítulo
Capítulo III
GESTIÓN Y BUEN GOBIERNO DE CENTROS Y
SERVICIOS SANITARIOS PÚBLICOS.
Capítulo IV
LA
PROFESIÓN
MÉDICA:
EL
MÉDICO
QUE
NECESITAMOS:
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6
PROPUESTAS
Capítulo I
EL SNS: FINANCIACION Y SOSTENIBILIDAD
I.1 Marco de referencia:
El llamado Sistema Nacional
Nacional de Salud español (SNS) es el resultado de un
complejo proceso histórico, a lo largo del cual se ha ido produciendo una
migración progresiva de un modelo vinculado a la Seguridad Social y financiado
por cuotas, hacia otro inspirado en los Servicios Nacionales de Salud de
orientación poblacional y financiado por impuestos. Además, este proceso se ha
acoplado con una descentralización de competencias y financiación a las
Comunidades Autónomas (CCAA), que han recibido la transferencia de la
inmensa mayoría de establecimientos de titularidad pública de las diferentes
administraciones (la Seguridad Social retiene el patrimonio en los suyos). Desde
enero de 2002, las CCAA se configuran como la administración territorial
especializada en la gestión de servicios de bienestar social tan importantes como
la sanidad, la educación y los servicios sociales; la sanidad es el que mayor peso
económico tiene, con cerca del 40% del presupuesto de gastos.
Los consensos políticos para la construcción del SNS no han sido fáciles. La
Ley General de Sanidad de 1986 promovida por el PSOE (Ministro Ernest Lluch),
fue políticamente convalidada por el Partido Popular (Ministro José Manuel
Romay) en 1998, cuando el dictamen de la Subcomisión Parlamentaria de
mejora y racionalización del Sistema Nacional de Salud dio por válida la
arquitectura institucional del SNS. Esta convergencia entre los dos partidos
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transferencia plena del INSALUD en enero de 2002, y b) con el nuevo modelo
7
mayoritarios incorpora las expectativas nacionalistas y regionalistas: a) con la
de la Ley 21/2001 que otorga una financiación no finalista a las CCAA y una
amplia autonomía por el lado de los gastos para gestionar el conjunto de
servicios transferidos. Este amplio consenso se plasmó en la aprobación en 2003
de la Ley 16/2003 de Cohesión y Calidad del SNS, promovida por la Ministra
Ana Pastor, que intenta aportar instrumentos de coordinación de un SNS con
una arquitectura extremadamente descentralizada.
En relación a la cobertura del SNS,
SNS La conciencia mayoritaria de la
sociedad española avaló cada paso de la extensión de la acción protectora
sanitaria de la Seguridad Social, incluidas las personas sin recursos (Real Decreto
1088/89), y tras la reforma promovida por el gobierno de Aznar con la Ley
Orgánica
4/2000
de
extranjería,
extendida
a
aquellos
inmigrantes
empadronados.
Un eje de consenso menor fue la reforma de las formas de gestión de las
instituciones sanitarias, y el modelo de vinculación de personal (ambos temas
estrechamente ligados).
En lo referido a las formas de gestión de los centros sanitarios públicos,
públicos
era ampliamente compartido el diagnóstico de que el modelo
administrativo y funcionarial para la gestión de servicios complejos de
tipo profesional (sanidad) no era el más apropiado. Pero en las
alternativas había menor consenso.
En lo referido al modelo de vinculación de personal,
personal el debate entre
laboralización o funcionarización ocupó una década, durante la cual se
fueron paralizando los concursos, y se acumularon y enquistaron
situaciones de interinidad y contrataciones eventuales y precarias
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8
insostenibles.
En la práctica, todos los debates suscitados desde el Informe Abril de 1991,
tanto en el dilema laboralización/funcionarización, como en las experiencias de
consorcios, fundaciones y empresas públicas, se saldaron en un texto legal (Ley
15/1997 de habilitación de formas de gestión), una orientación de facto de la
vinculación estatutaria (vía OPE extraordinaria de la Ley 16/2001 para
consolidación de personal), y el tardío Estatuto Marco del personal (Ley
55/2003), cuyas holguras han sido reinterpretadas a nivel central y autonómico
en clave funcionarizante.
La aplicación de cambios fue tímida, incompleta y limitada. En la práctica,
las innovaciones en gestión institucional y de personal se han puesto en marcha
en centros o servicios de nueva creación, creando un sistema dual de centros
sanitarios con modelo administrativo (de tamaño grande y mediano), y otros
con modelos asimilables a empresas o entes públicos (con tamaños menores).
El consenso en innovar la
gestión pública, no consiguió implicar ni a
Izquierda Unida, ni a los sindicatos CCOO y UGT; tampoco consiguió
entusiasmar a los sindicatos profesionales. Desde 1999, se produce una mayor
divergencia con el desarrollo en la Comunidad Valenciana de alternativas de
concesión de la asistencia sanitaria pública a empresas privadas (que luego se
extendió a Madrid y otras CCAA en diferentes variantes de la “colaboración
público-privada”). La externalización ha sido un eje permanente de controversia
política, sindical, profesional y social, y ha limitado las posibilidades de cristalizar
un acuerdo amplio de reformas institucionales.
Por todo lo anterior, la construcción del SNS fue acumulando una serie de
debilidades institucionales
institucionales,
nales y sorteando en cada etapa la necesidad de acometer
reformas estructurales que estaban razonablemente identificadas; la incapacidad
política e institucional para gestionar cambios, se acompañó tras 1996 de una
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expandir el sistema y evitó enfrentarse a los verdaderos problemas. La crisis
9
larga etapa de crecimiento económico que disipó las tensiones y permitió
económica iniciada en 2008 ha supuesto una ruptura abrupta en la trayectoria
histórica, que evidencia las debilidades institucionales y está suponiendo un
riesgo importantísimo para la sostenibilidad del SNS. La opción planteada por el
Gobierno, expresada en el Real Decreto Ley 16/2012, inicia una senda contraria
al lento avance experimentado en los consensos básicos que han conformado la
trayectoria histórica del SNS.
I.2 Datos comparativos:
Como complemento al marco de referencia, adjuntamos las siguientes
figuras que facilitan la comprensión de los aspectos financieros del SNS:
En la figura 1 se evidencia la conocida situación de costes económicos
razonables del SNS español, cuando lo comparamos con los demás países de la
OCDE (España suele comportarse como valor medio de la UE-27, y con un gasto
sanitario notablemente menor frente a los países de la UE-15).
Figura 1:
1 Cuadro comparativo de Gasto Sanitario per cápita (público y
privado) en dólares (ajustados por paridad de compra) entre países de la OCDE
Página
http://www.oecd.org/dataoecd/6/28/49105858.pdf: Página 151.
10
en el año 2009. Tomado de Health at a Glance 2011 - OECD INDICATORS:
Pero, como se observa en la figura 2,
2 el ritmo de crecimiento entre 2000
y 2009 fue superior al del PIB (2,5 veces más rápido), siendo el doble en el caso
español (5 veces mayor el crecimiento del gasto sanitario que el crecimiento del
PIB); sólo cuatro países europeos superaron a España: Dinamarca, Bélgica, Italia e
Irlanda. La pregunta es si en esta fase de crecimiento acelerado los incrementos se
aplicaron de forma suficientemente racional.
Figura 2:
2 Tasa anual de crecimiento en gasto sanitario per cápita, 20002009 (abscisas) relativo al crecimiento del PIB (ordenadas) en países de la OCDE:
línea inferior (azul) crecimiento igual que el PIB; línea media (roja), pendiente
crecimiento OCDE; línea verde, pendiente de crecimiento de España. Tomado y
modificado
de
Health
at
a
Glance
2011
-
OECD
INDICATORS:
http://www.oecd.org/dataoecd/6/28/49105858.pdf: página 151
En la figura 3 se evidencia para el gasto sanitario público en el período
2002-2008 la evolución de los incrementos interanuales: en la mayoría de
anualidades un punto superior el crecimiento del gasto sanitario público; pero en
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del inicio de la crisis económica (2008/2007), se aprecian notables diferencias
11
el año de la transferencia sanitaria completa del INSALUD (2003/2002) y en el
entre ambas tasas de crecimiento a favor del gasto sanitario público.
Figura 3:
3 evolución del crecimiento interanual del PIB y del Gasto
Sanitario Público en el período 2002-2008; Fuente: estadísticas de gasto sanitario
/ Ministerio de Sanidad, Servicios Sociales e Igualdad; elaboración propia.
El largo período de crecimiento en
la financiación sanitaria pública,
supuso incrementos en los recursos humanos del sistema; en la figura 4 se
compara para los hospitales de titularidad pública (tamaño medio de 420 camas)
el crecimiento porcentual de recursos humanos (51% médicos y 38%
enfermeras) comparado con el incremento de una parte relevante de la actividad
asistencial (33% de aumento en la suma de altas e intervenciones por Cirugía
Mayor Ambulatoria). Es de justicia mencionar que la complejidad de casuística
puede estimarse que creció en torno a un 12% (como efecto del envejecimiento
o porque la red de grandes y medios hospitales públicos concentrara los casos
Página
12
más complejos).
Figura 4:
4 Incremento en 12 años de médicos, enfermeras, y actividad
(altas+CMA) en hospitales de titularidad pública. Fuente ESCRI y datos estudio
OMC – Demografía Médica 2011
En la figura 5,
5 vemos el efecto de la crisis económica, a través del
presupuesto por persona protegida por las CCAA; el presupuesto es una
magnitud que no coincide con el gasto liquidado ni con el gasto real, pero es la
única magnitud que tenemos con fechas actuales para reseñar la evolución de los
últimos tres años. Tras 2009, donde se llega al pico de 1261 €, se inicia el
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Figura 5:
5 evolución de los presupuestos iniciales de las CCAA, expresados
13
descenso que en 2011 llega a 1.229 €.
en forma de presupuesto por persona protegida, desde 2007 hasta 2011. Tabla
tomada de estudio del Ministerio de Sanidad, Servicios Sociales e Igualdad y
modificada para presentación.
http://www.msps.es/estadEstudios/estadisticas/inforRecopilaciones/docs/Recursos
_Red_2011.pdf
Y, finalmente, en la figura 6,
6 se expone la expectativa del gobierno en
Mayo 2012 de llevar el gasto sanitario público del 6,5 (% del PIB) existente en
2010, a un 5,1 % en 2015 (reducción de la participación de la sanidad en la
riqueza nacional de un 21,3% de los gastos en 5 años escasos).
Figura 6:
6 Escenario de reducción del peso de gasto sanitario público en
relación al PIB 2010-2015 dentro de la actualización del Programa de Estabilidad
de España(Mayo 2012).http://www.lamoncloa.gob.es/NR/rdonlyres/8A9ED6BD9183-41EA-A8AC-4DA56487D8E/202009/ActualizacinProgramaEstabilidad2.pdf
Página
Cabe hablar de cuatro grandes problemas, que surgen de la conjunción de
14
I.3 Identificación de problemas:
la crisis económica con los problemas estructurales y las debilidades
institucionales del SNS.
1) Problemas de suficiencia presupuestaria:
presupuestaria en la historia de la sanidad
pública española, cabría hablar de una infra-presupuestación estructural,
por la cual en muchas anualidades se partía de dotaciones económicas a la
baja respecto a las proyecciones de gasto. Esto ha llevado a devaluar los
presupuestos como instrumentos de gestión, y a requerir cada cuatro o
cinco años operaciones de saneamiento
para pagar las deudas
acumuladas. A esto se ha añadido el efecto de la crisis sobre los Ingresos
Tributarios del Estado, la tardanza en comenzar las operaciones de ajuste,
y la amplitud y rapidez de los recortes en el gasto sanitario público que se
plantean desde el año 2011.
La sanidad se basa en activos altamente específicos (profesionales,
tecnologías, centros…) que no se benefician de crecimientos rápidos: la
expansión acelerada del 2002 al 2009 mostró que una cosa era construir
centros y otra dotarlos de especialistas cualificados. Pero, también, que no
cabe hacer reducciones por encima del 3-4% anual sin que ello suponga
una destrucción de dichos activos y la erosión de la funcionalidad de los
centros y servicios sanitarios.
La contención del gasto sanitario
sanitario público puede y debe hacerse desde la
inteligencia profesional y gestora.
gestora Los cambios estructurales orientados a la
gestión del conocimiento y a la desinversión en lo que no añade valor,
son estrategias de relevancia fundamental para la racionalización de la
asistencia. Los recortes en personal, prestaciones y en cobertura a
inmigrantes plantean enormes dilemas éticos a la profesión médica, que
no puede aceptar sin más un cambio en la misión y vocación universalista
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15
del Sistema Nacional de la Salud.
La reciprocidad con transeúntes, turistas o residentes de otros países
parece un principio lógico y razonable. No parece tan fácil aplicarlo
cuando hablamos de inmigrantes de lugares donde los Estados son frágiles,
el poder es despótico, y las economías sólo permiten la subsistencia. En
todo caso, las políticas de control de la inmigración son las que deben
materializar la voluntad de la sociedad en el grado de acogida y
regularización de inmigrantes. Pero, una vez que están dentro de España,
no deben ser los médicos ni los sanitarios los que se vean ante el dilema
ético de racionar o dosificar la prestación asistencial. Por otra parte,
limitar la atención primaria y dejar sólo la puerta de urgencias, es una
forma escasamente inteligente de abordar el reto, desde la perspectiva
clínica y de salud pública.
Hay alternativas para la suficiencia y la sostenibilidad que pueden
articularse si se limita la compulsión y se establece un marco temporal
razonable, y unos instrumentos de diálogo político, institucional,
profesional, sindical y social que permitan a todas las partes implicadas
expresar sus ideas y formalizar sus compromisos
2) Problemas de cierre del modelo de universalización y definición positiva
de “ciudadanía sanitaria”; en efecto: no hay una definición en positivo del
SNS ni de su gobierno colegiado; ni tampoco del concepto de cobertura
universal y ciudadanía sanitaria. Parece contradictorio que un sistema
financiado por impuestos pueda negar la extensión de cobertura a
personas con recursos que sin embargo no acreditan cotización a la
Seguridad Social. Por otra parte, los extranjeros sin recursos y que viven
en España sin registro ni autorización, no pueden estar a extramuros de la
asistencia integral y programada del SNS, tanto por razones bioéticas,
como de efectividad clínica y preventiva. Los cambios planteados en el
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profundizar en el concepto de ciudadanía sanitaria del SNS, retroceden a
16
Real Decreto Ley 16/2012 no van por el camino correcto,
correcto pues en vez de
una definición Bismarckiana de aseguramiento vinculado a cotización o
prestaciones de la Seguridad Social, y vuelven a otorgar al Instituto
Nacional de la Seguridad Social un papel determinante en la definición y
clasificación de asegurados y beneficiarios.
3) Problemas de Buen Gobierno y Buena Gestión:
Gestión la debilidad de las reglas
institucionales facilita el comportamiento oportunista de los agentes. Se
transfieren obligaciones a las CCAA sin que la financiación sea suficiente
en muchos casos; pero el ciclo expansivo de la economía alimenta una
alianza de todos los agentes (incluido el entramado industrial tecnofarmacéutico) a favor del crecimiento en centros, servicios, plantillas,
salarios y prestaciones, que supera ampliamente la capacidad de
financiación establecida en el modelo de la Ley 21/2001. Los sistemas de
colaboración público-privada permiten hacer más hospitales y demorar el
pago a la siguiente legislatura y a las generaciones venideras; la no
contabilización de pagos a proveedores de tecnología y medicamentos
embalsa la deuda para futuras operaciones de saneamiento; y de esta
manera se prepara el colapso de financiación de 2010. No es
gobierno: con el
estrictamente un problema económico, sino de mal gobierno
crecimiento indexado al PIB y una reflexión más racional sobre la
expansión de centros y servicios, se podría haber ajustado una trayectoria
de mejora de los servicios a medio plazo, contando con la racionalización
de desarrollar los cambios estructurales y de gestión necesarios. La propia
crisis financiera internacional, en último término tiene también una génesis
en el mal gobierno de los bancos, las entidades de crédito, los fondos de
inversión y las agencias de auditoría y rating. Por eso la salida a la
sostenibilidad del SNS requiere encontrar una senda virtuosa para que el
Buen Gobierno y la Buena Gestión minimicen los riesgos de que la
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4) Problemas de subdesarrollo de la Gestión Clínica, la Integración Asistencial
17
necesaria autonomía gestora devenga en arbitrariedad.
y el Profesionalismo
Profesionalismo como alternativa de cambio estructural del SNS.
En la gran mayoría de países desarrollados desde hace una década se está
trabajando en un cambio estructural de la medicina y los sistemas
sanitarios,
sanitarios a partir de elementos bien conocidos como la medicina basada
en la evidencia, la gestión del conocimiento, la gestión clínica, la
departamentalización de hospitales, el trabajo por procesos integrados, las
estrategias de cronicidad, la coordinación socio-sanitaria, etc. La debilidad
de los recursos de media y larga estancia, y de atención a la dependencia
hacen muy importante la activación de todos los mecanismos que
potencien la activación de recursos sociales desde el sector sanitario.
También ha habido un cambio en el paradigma de gestión:
gestión de modelos
que transitaron entre la jerarquía de base administrativa y el gerencialismo de
corte industrial, se ha pasado a reconocer que la sanidad es una organización de
servicios de tipo profesional, y que su buena gestión exige rediseñar el contrato
social con los profesionales y promover la delegación responsable, la rendición
de cuentas, la reducción de conflictos de interés, y la cultura cooperativa y de
excelencia. La micro-gestión es la clave.
A pesar de los avances puntuales que se han producido en España, no
cabe decir que el SNS haya tenido una estrategia decidida en ésta línea. Tres
factores han dificultado esta reorientación estratégica y cultural del SNS:
a) La excesiva politización partidaria,
partidaria con su sesgo miope y cortoplacista, y
su renuencia a llegar a acuerdos de amplia base y largo alcance; esto ha
producido un sesgo de intervencionismo de la Macro-gestión sobre todos
los asuntos, restando espacio a la Meso-Gestión (gerencias y direcciones
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autonomía real y responsable a la Micro-Gestión.
18
médicas y de enfermería), y erosionando la posibilidad de otorgar
b) Una cultura de gobierno autocomplaciente y negadora de los problemas,
problemas
que derivaba todas las tensiones alimentando un escenario expansionista y
providencialista; en el contexto de la descentralización a 17 CCAA, esto
provoca una tendencia inflacionaria en recursos (competir al alza para
evitar diferencias y agravios comparativos); también promueve una
extraña pugna de marketing político para mostrar grandes avances
tecnológicos, pero no una competencia en resultados para promover la
excelencia (los sistemas de información no aportan el marco comparativo
necesario, y la información “delicada” se oculta celosamente).
Los
gerentes hospitalarios van perdiendo legitimidad y autoridad por el
achique de espacios que produce la macro-gestión politizada, y ante la
dificultad de manejar conflictos cuando está altamente penalizado el ruido
mediático: esta ausencia de meso-gestión no beneficia a la micro-gestión:
produce desgobierno; también inseguridad y discontinuidad de proyectos
de cambio, dado que cualquier alternancia política altera la continuidad
de los equipos directivos.
c) La desconfianza en los profesionales se mantiene,
mantiene a pesar de que la
profesión médica consolida cambios sociológicos, organizativos y éticos
de gran relevancia e interés social, y contra la evidencia de los estudios de
organización, que aconseja potenciar la autonomía de los micro-sistemas
clínicos. Los responsables políticos e institucionales hace dos décadas
(visión socialdemócrata) mantenían una relación adversarial con la
profesión médica por el desajuste intrínseco del desempeño profesional
con
los
modelos
jerárquicos
administrativos;
hoy,
desde
la
postmodernidad (visión liberal-conservadora) se reedita e incluso
recrudece esta distancia, al propugnarse modelos de control contractual
basados en el pago fragmentado por ítems de servicio o sistemas
alambicados de algoritmos de productividad variable.
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correctas para una relación que debe estar asentada en la confianza, la
19
Ni la suspicacia weberiana ni la emulación de mercado son respuestas
ética, y la rendición integrada de resultados en términos de ganancia de
salud, seguridad, calidad y satisfacción de los pacientes. Encontrar estos
modelos de profesionalismo activo es esencial para garantizar la
sostenibilidad de los sistemas públicos de salud y también para superar la
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20
crisis de la medicina y el queme de los médicos.
Capítulo II
LA NECESIDAD DE UN GRAN ACUERDO POLITICO
La posición desde la que los profesionales piden un Acuerdo político no es
la de una defensa a ultranza de soluciones técnicas (por supuesto a un problema
técnico) implementadas por técnicos. Entendemos perfectamente la naturaleza
política de las reformas sanitaria y precisamente por eso pensamos que se
requieren negociaciones inteligentes y productivas en el ámbito político,
convencidos, como estamos, de que existen muchos elementos de esa naturaleza
en las decisiones que afectan al SNS.
Al mismo tiempo constatamos que entre los grandes partidos españoles
no existen diferencias en lo que respecta a los grandes principios que informan la
existencia y el funcionamiento de nuestro sistema sanitario. Por otra parte,
observamos que entre los países avanzados de la UE, cuyas sociedades son en
muchos casos más igualitarias que la nuestra, existe una variedad significativa de
modelos de sanidad pública, todos ellos plenamente enmarcados y compatibles
con un Estado de bienestar desarrollado. Ello significa que existe un amplio
espacio de negociación y acuerdo sin que signifique necesariamente alterar las
bases fundamentales del sistema. Este es el tipo de pacto factible que,
renunciando a maximalismos con frecuencia electoral o clientelarmente
interesados, se puede y debe alcanzar.
En este sentido, los médicos quieren ser protagonistas activos de este
Acuerdo que podría revestir la forma de un apoyo explícito a esta propuesta de
la OMC y que establezca una serie de iniciativas concretas que permitan mejorar
la efectividad y eficiencia en el uso de los recursos sanitarios ofreciendo servicios
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Para ello se requerirá en todo caso máxima independencia en la
21
de verdadera calidad.
organización y gestión de todas las organizaciones asistenciales, máxima
transparencia informativa, un marco financiero definido y estable, sin perjuicio
de la necesaria flexibilidad teniendo en cuenta las cambiantes circunstancias
externas y un marco de cooperación entre CCAA que permita utilizar los recursos
(humanos y materiales) del conjunto del sistema de manera eficiente.
Enfrentados a la confección de un documento que busque el deseado
consenso, lo primero en que se piensa es en una serie de actuaciones inmediatas
que un grupo de expertos (en este caso, un grupo de médicos) considera que son
las adecuadas. Por ejemplo, qué tipo y cuantía de copago debe admitirse, como
tiene que ser la carrera profesional, qué incentivos hay que crear o que
prestaciones deben y no deben financiarse, incluyendo los medicamentos.
Creemos, sin embargo, que no es este el documento que habría que preparar.
Pensamos más bien que el acuerdo político debe ser aquel que libere las
potencialidades del sistema sanitario y de todos sus partícipes y contribuya a
superar las situaciones de bloqueo que todos conocemos y que desde hace
muchos años impiden reformas necesarias.
¿Cuáles son esas situaciones? Probablemente algunas se queden en el
tintero, pero no es difícil identificar la tendencia al “café para todos” que impide
a cualquier nivel, sobre todo en el de los recursos humanos, discriminar a favor
de la excelencia en procesos y resultados. De ello sería un ejemplo la tendencia a
crear estructuras o dotar servicios con fines electorales o directamente
clientelares. Por otra parte, también la dificultad para y la resistencia a valorar
objetivamente la eficiencia relativa de instituciones públicas y privadas
financiadas públicamente en el logro de resultados de calidad (es obvio que si
hay riesgos de calidad/eficiencia en situaciones de provisión privada, también los
hay en el caso de la provisión pública y que la objetivación de las distintas
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Por consiguiente, el acuerdo tiene que abordar más bien los instrumentos
22
situaciones exige un abordaje descargado de prejuicios).
promoviendo, la creación de estructuras estables y muy profesionales que
puedan efectivamente identificar los problemas de todo tipo que hoy dificultan
el buen funcionamiento del sistema y plantear las soluciones adecuadas, teniendo
en cuenta consideraciones políticas, económicas, sociales y, desde luego,
manejando criterios técnicos debidamente contrastados. En definitiva, robustecer
la institución que es la sanidad pública, haciéndola más “inclusiva” en términos
de sociedad civil y, por tanto, más sólida e independiente.
En ese sentido, abogamos para que las estructuras directivas desde el
máximo nivel, tanto en el Ministerio como en los departamentos de salud de las
CCAA, se ocupen por profesionales de reconocido prestigio. También
planteamos que se cree (o se configure algo que ya existe) un órgano
independiente encargado de identificar desinversiones y aprobar, en su caso
nuevas inversiones/prestaciones Asimismo planteamos la creación de otro
organismo igualmente independiente responsable de la evaluación permanente
de todas las instituciones sanitarias, sus procesos y resultados ofreciendo con
absoluta transparencia los datos pertinentes. Este sería
el modo de superar
debates estériles apoyados en una mezcla de prejuicios y opacidad y que tanto
tiempo hacen perder. Los partidos políticos deben comprometerse a establecer
los procedimientos necesarios para que este tipo de independencia sea una
realidad en el plazo más corto posible.
Todo ello que significa, en último extremo, que en el nivel político
quedarían las grandes decisiones que son el QUE servicios se prestan con recursos
públicos, el CUANTO –volumen de recursos que se destinan a asistencia sanitaria
(conviene no olvidar que hay otras políticas con impacto favorable sobre la
salud y que no son sanitarias)- y la garantía del principio de equidad. Como es
natural, el nivel político es el facultado para exigir responsabilidades a los niveles
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23
directivos, pero no para sustituirle en sus actuaciones.
Este Acuerdo permitiría alcanzar un consenso acerca del funcionamiento
del SNS, manteniendo al poder político dentro de los límites que le
corresponden, permitiendo estabilidad en el desarrollo de unas actividades
profesionales independientes, plenamente dirigidas a obtener la máxima
eficiencia y calidad, todo dentro de un esquema de transparencia que permita a
la sociedad conocer que uso se da a sus impuestos y con qué resultados. Y
enfrentando a cada agente o parte del sistema con su responsabilidad a través de
un
mecanismo
explícito
de
rendición
de
cuentas.
Profesionalmente, no podemos entender y mucho menos aceptar la permanente
utilización del tema sanitario como escenario de confrontación partidaria cuando
por otro lado todos proclaman las excelencias de modelo de SNS y manifiestan
(fuera de escena) un grado de acuerdo considerable en casi todo. Semejantes
incoherencias alcanzan niveles patéticos cuando el mismo partido defiende en
temas sanitarios posiciones contrarias según esté en el poder o en la oposición o
en una u otra Comunidad Autónoma contribuyendo al descrédito y desprestigio
de lo político.
La actual situación de emergencia económica obliga a duros, dolorosos,
polémicos
y probablemente inevitables ajustes a corto plazo. Admitimos la
existencia de un cierto nivel de pasión en su defensa y en su rechazo, pero
habremos de arrinconarla para configurar y defender las reformas estructurales
que se proponen y que también vehementemente pedimos sean aceptadas y
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24
consensuadas de modo explícito y público por las fuerzas políticas concernidas.
Capítulo III
GESTIÓN Y BUEN GOBIERNO DE CENTROS Y SERVICIOS SANITARIOS
PÚBLICOS
Una actividad de la envergadura social y económica de la atención
sanitaria pública debiera suponer la participación efectiva y corresponsable de
ciudadanos y profesionales en orden a conseguir el mejor uso de los servicios
sanitarios.
Los profesionales por su parte deben contribuir de forma proactiva a la
mejora de la eficiencia y calidad del SNS, implicándose con responsabilidad
plena en la organización, funcionamiento y toma de decisiones que afectan a
la prestación de los servicios.
Aunque mucho se ha hablado de la participación de los médicos en la
gestión del SNS, poco se ha hecho al respecto, más allá de su presencia en
comités asesores, receptores de notificación de novedades organizativas y de la
ubicación de algunos profesionales en distintas posiciones en la estructura de
gestión. Tal clase de participación es además de profesionalmente insatisfactoria,
funcionalmente inútil por cuanto no transfiere responsabilidad y riesgo a los
médicos. No es esa la aspiración de los profesionales. Por la propia naturaleza
del quehacer clínico los médicos han de tener un protagonismo central decisivo
en el SNS, expresado en un liderazgo efectivo que ha de concretarse tanto en el
nivel estratégico como en la implementación de programas específicos.
Obviamente el correlato de dicho protagonismo en las decisiones implica
la asunción de responsabilidades. Responsabilidad, riesgo y rendición de cuentas
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fuerte compromiso con la sociedad y es consciente de que los recursos a su
25
son elementos que deben acompañar al protagonismo. La profesión tiene un
disposición no son ilimitados. Pero también sabe cómo dar el mejor uso posible
esos recursos.
En modo alguno se pretende desplazar y exonerar a los poderes públicos
de sus obligadas y legítimas responsabilidades ante la ciudadanía en materia
sanitaria, mas bien al contrario se les exigirá que realmente gobiernen y piloten
esta nave tan a menudo a la deriva que resulta ser el SNS para lo que resulta ser
imprescindible la implicación corresponsable y efectiva de los profesionales en
diferentes niveles y para distintas tareas.
Las líneas de trabajo y cambio que se proponen se detallan a continuación
III. 1 Órganos de representación y participación colegiada
Para ejecutar esta deseada participación de los profesionales en el SNS,
nos permitimos formular las siguientes propuestas, siempre sometidas al
oportuno debate y valoración.
a) Macro-participación para el conjunto del Sistema Nacional de Salud, en el
ámbito del Estado. Para su viabilidad, esta macro-participación exige, al
menos, tres requisitos esenciales: la objetividad e independencia, la alta
cualificación de los partícipes y la capacidad real de decisión. En ese
sentido, parece oportuno que se instrumente en el ámbito del Parlamento
español, como una comisión dependiente de la representación popular.
En aras a la eficacia se debe determinar, también, el alcance y contenido
de las materias objeto de abordaje; la necesaria formulación de consulta
preceptiva previa, no vinculante, para la adopción de las diferentes
decisiones; y los integrantes de la comisión, que deberán proponer
corporaciones
u
organismos
profesionales, las sociedades científicas,
como
los
colegios
las universidades, o la
tecnoestructura del Ministerio de Sanidad o del Gobierno de la Nación.
26
entes,
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distintos
b) Una participación más reducida a nivel territorial, con especial
protagonismo de los servicios autonómicos de salud, que es donde se
adoptan las medidas de gestión que afectan al sistema y tienen una
repercusión inmediata. Este nivel participativo debe tener su sede en los
correspondientes parlamentos regionales. Su elección y control deben
seguir las mismas pautas que las señaladas en el apartado anterior.
c) Por último, resulta
oportuno habilitar un sistema de participación y
decisión en cada área de gestión integrada, o en modelos similares. Las
actuales juntas facultativas. técnico-asistenciales, comisiones mixtas, u
otros órganos de participación equivalentes, no funcionan y, si lo hacen,
es mediante reuniones de limitado alcance o de escasa o nula eficacia.
Para la elección de sus integrantes, de la mayor cualificación y objetividad,
debe optarse por un sistema ágil y nada farragoso.
Sus competencias y
funciones deben ser las ya señaladas en los casos anteriores. Siempre
preceptivas, aunque no vinculantes, en aquellas materias y decisiones de
relieve, incluso las que afecten a las potestades organizativas de las
Administraciones.
III. 2
Profesionalización de directivos
Mayor profesionalización y menor injerencia política, en los puestos de
gestión de los centros sanitarios. Semejante obviedad debe ser señalada y
subrayada una vez más por cuanto, aunque algo se ha mejorado, es preciso
insistir en ello para asegurar una mayor continuidad y estabilidad de las
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27
organizaciones.
III. 3 Reformas en el ámbito organizativo y retributivo
Se debe romper con la clásica estructura de nivel asistencial (atención
primaria por un lado y atención especializada por otro), y promover la
integración real de proveedores que atienden a una población. Eso exigiría que
el conjunto de proveedores que atienden a esa población compartan un
presupuesto, ajustado al tipo de población que atienden, y orientado a mantener
a la población sana.
En el caso particular de la Atención Primaria, co-protagonista de la
necesaria reorientación asistencial hacia los cuidados de larga duración; los
equipos de atención primaria deben asumir una capacidad real de autoorganización, así como manejar instrumentos para actuar como agentes de sus
pacientes ante la red sanitaria y socio-sanitaria.
Se propone también ensayar un cambio de modelo contractual que se
aleje de la actual integración vertical –empleados públicos cuyo salario depende
prácticamente de su statu quo, que trabajan en centros de titularidad pública-, y
adopte el formato de agrupaciones de profesionales con las que el financiador
público contrata servicios cualificados tras evaluación. Se trataría de fomentar
modelos asimilables al trabajo por cuenta propia.
propia
En la mayoría de países de nuestro entorno la atención primaria no está
integrada en la función pública, sino que se vincula por un sistema contractual; el
financiador público desarrolla una regulación amplia, pero se basa en la
autogestión de los centros de salud por parte de sus profesionales. Los modelos
de financiación son diversos, pero son muy comunes el componente capitativo y
la existencia de incentivos en función del cumplimiento de objetivos y la
generación de ahorros. La iniciativa pionera de las Entidades de Base Asociativa
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resultados positivos en el marco organizativo del SNS.
28
en Cataluña demuestra que estas experiencias pueden ser aplicables y ofrecer
La remuneración debe tender a favorecer la longitudinalidad, debe
aumentar el peso del componente capitativo y de los incentivos, cuya misión
principal es alinear clínica y gestión, Se debe garantizar una estabilidad en los
incentivos, para evitar que sean la primera partida a suprimir en épocas
contractivas de la economía.
Por otra parte, presupuestar la atención sanitaria a una población
(financiación
financiación capitativa
capitativa)
tiva en lugar de seguir presupuestando por los servicios
sanitarios de distintos proveedores poco coordinados, favorecería la integración
asistencial ayudando a evitar entre otras duplicidades, retención de pacientes y la
iatrogenia de exceso de tecnología. Obviamente, estos modelos capitativos
deberían incorporar tanto ajustes de riesgo (necesidades de la población), como
modulaciones por tendencias históricas de frecuentación y gasto.
Permeabilizar el trasiego de profesionales entre especialidades, reduciendo
los silos de producción actuales: cada especialista se forma y trata a los pacientes
desde el “órgano” del cuerpo en el que está especializado, olvidando que trata
pacientes complejos. Ligado al anterior, y considerando la tipología de pacientes
más prevalentes en nuestras sociedades es necesario reorganizar los servicios en
función de la trayectoria clínica esperable para cada tipo de paciente: un
paciente crónico, verá a lo largo de su vida numerosos especialistas. El objetivo
sería evitar que este paciente disponga de un juicio clínico independiente por
cada médico que lo ve, a veces contradictorio, y proporcionarle un plan de
cuidados coordinado.
Las medidas organizativas van de la mano con la necesidad de evaluar y
retribuir en función de desempeño (esfuerzo y resultados), tanto a los
profesionales, como a los centros sanitarios que proveen los servicios. Debería
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necesariamente implican añadir más salud.
29
limitarse el pago por acto allí donde proporcionar más servicios, no
Es necesario dejar atrás comportamientos paternalistas y dar paso a toma
de decisiones compartidas.
compartidas Informar de los mejores cursos de acción en los
múltiples ejemplos de toma de decisiones compartidas, que logran disminuir el
porcentaje de usuarios pasivos, de pacientes indecisos, que con información
correcta tienden a usar tecnologías menos invasivas y a tomar decisiones de
mayor calidad. Se evita también el exceso de mortalidad que provoca la falta o
baja alfabetización en salud. El paciente es quien debe saber cómo conservar su
salud, el profesional conoce los medios diagnósticos y terapéuticos para intentar
recuperarla. Tener en cuenta los valores, preferencias del usuario del sistema
sanitario y el balance riesgo beneficio de las opciones que ofrece el profesional
produce decisiones más acertadas. Paciente experto, aulas de pacientes y
universidades de pacientes son otros ejemplos de cómo disminuir demanda
asistencial mejorando a su vez el control de la enfermedad y la seguridad clínica.
Con el empoderamiento individual se trata de que el paciente tenga mayor
vigilancia sobre las decisiones y acciones que afectan a su salud personal. Con el
empoderamiento colectivocolectivo-comunitario,
comunitario actuaciones colectivas que produzcan
cambios en los determinantes de salud mejorando el entorno donde vive el
usuario, un entorno promotor de salud. Existe demasiada dependencia del
sistema sanitario como determinante de salud. Si los determinantes sociales son
los mayores determinantes de la salud, así deben ser las soluciones.
III. 4
Práctica
Práctica médica apropiada, Evaluación de Tecnologías y Cartera de
Servicios
El reto del profesionalismo médico sigue siendo aportar valor a la salud
de individuos y poblaciones. Es preciso desterrar de la práctica las intervenciones
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Es imperativo un cambio en el paradigma ético.
ético Del “para mi paciente lo
30
sanitarias que no añaden valor y pueden producir daño.
mejor no importa su coste” al “dados recursos finitos, muchos pacientes no
podrán recibir los mejores cuidados si en mis decisiones se produce desperdicio
de recursos”. Este cambio de paradigma, tiene una derivada directa en cuanto al
principio primum non nocere
nocere. La aplicación de técnicas sin valor o de dudoso
balance entre beneficios y riesgos, ponen a riesgo de daño innecesario a los
pacientes o poblaciones que las reciben.
1. Medicina de dudoso valor.
Es imprescindible ser conscientes de la magnitud del fenómeno.. Entre el
30% y el 50% de las decisiones médicas no añaden valor a la salud los pacientes
o poblaciones que son afectadas; por consiguiente, entre un 30% y 50%, los
costes asociados son equivalentes a desperdicio de recursos. En España existen
numerosas pruebas de la producción de cuidados de escaso valor; algunos
botones de muestra: 55% de faringoamigdalitis inadecuadamente tratadas, 53%
de mujeres con tratamiento anti-osteoporosis mal indicado, 8% de ingresos y 10
por mil de consultas derivaron en algún evento adverso, 12% de ingresos
relacionados
con
problemas
en
medicación,
3%
de
hospitalizaciones
potencialmente evitables en enfermos crónicos, una diferencia injustificada en
gasto hospitalario estandarizado cápita de 2 veces entre áreas sanitarias, 1 caso
tromboembolismo o trombosis por cada 500 intervenciones quirúrgicos
atribuible a algún déficit en los cuidados, diferencias de hasta 4 veces en el acceso
a cirugía conservadora
de mama, incremento en el gasto cápita que no se
convierte en equivalentes de salud, decenas de miles de casos de cirugía
potencialmente evitables por existir alternativas terapéuticas más efectivas, etc.
Una mirada a los estudios de variabilidad de práctica disponibles en
www.atlasvpm.org puede arrojar luz. Reconocer que a menudo las decisiones
médicas no añaden nada a la salud de los pacientes y las poblaciones, es el
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Esta situación obedece a diversas causas, como:
31
primer paso.
a) Cuidados innecesarios: incluyen tratamientos realizados sobre pacientes
que no los necesitan según la evidencia, o pacientes con serias dudas sobre
el balance entre beneficios y riesgos. Incluye, utilización innecesaria de las
tecnologías de más alto coste. La mal llamada “medicina defensiva” estará
también en esta categoría.
b) Servicios provistos de manera inapropiada e ineficiente: Especialmente
importante en nuestro sistema la fragmentación de cuidados (incluso
dentro del propio centro asistencial), el uso inapropiado de los recursos
(estancias prolongadas artificialmente, visitas médicas de seguimiento sin
valor, etc.) y consecuencias del error médico o de las complicaciones
atribuibles a cuidados deficientes.
c) Oportunidades de prevención desaprovechadas: En el terreno de la
prevención: abandono del consejo médico y la promoción de la salud
como parte del instrumental médico necesario, hospitalizaciones evitables
en pacientes crónicos, etc.
d) Uso indebido de recursos: ligado a conflictos de interés con otros agentes
del sistema, en particular, pero no sólo, la industria.
2. La experiencia internacional.
Otros lo han hecho. Las agrupaciones profesionales de países de
referencia, ya han iniciado el camino. Dos ejemplos de interés en Estados
Unidos:
1)
Choosing Wisely compendio de diversas iniciativas sobre
profesionalismo médico, con más de una década de aportaciones,
ha
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médicas (http://www.choosingwisely.org); 2) The Institutes of Medicine (IOM)
32
identificado un listado de prácticas innecesarias que afectan a 9 especialidades
ha considerado un imperativo elaborar una estrategia para disminuir costes
sanitarios, manteniendo o mejorando los resultados de salud. Para ello
consideran prioritario, reducir las hospitalizaciones evitables, evitar readmisiones
y
reducir
los
cuidados
innecesarios.
(http://www.nap.edu/catalog.php?record_id=12750)
3. Una Agenda de actuaciones
Es responsabilidad de los médicos liderar las reformas precisas, en un
debate leal con las autoridades sanitarias. La agenda de acciones que buscan
incrementar el valor es variada; una parte muy importante de la misma está
relacionada con hacer mejor Medicina
Medicina:
edicina
- Utilizando la mejor evidencia disponible
- Disminuyendo los cuidados innecesarios
- Mitigando los errores y las consecuencias ominosas de prácticas subestándar
- Eligiendo los recursos más eficientes para proveer los cuidados
- Mejorando la continuidad de cuidados
- Facilitando que, ante incertidumbre, el paciente comparta la decisión
- Cultivando la transparencia en los resultados y los recursos utilizados
- Reconociendo el fraude y persiguiéndolo activamente
También es responsabilidad de los médicos exigir lealmente una
administración más comprometida con el objetivo de añadir valor.
valor Para ello será
preciso:
- Construir sistemas de información que permitan disponer de la mejor evidencia
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retroalimentan con la experiencia diarias de médicos y servicios;
33
para tomar decisiones en situación de incertidumbre; sistemas que se
- Financiar selectivamente aquello (tecnologías, servicios, etc.) que añade valor;
para ello se deberá conferir un papel real, relevante y decisivo a los dictámenes
e informes de las agencias de evaluación de tecnologías en España, actualmente
organizadas en una sola red. Se trata de llevar a la vida real lo que formalmente
está recogido en el marco legal (Ley de cohesión y Calidad del SNS y otras
normas) usando de verdad
el producto de la información y conocimiento
independientes y fiables para la toma de decisiones político-sanitarias tal como se
ha hecho en otros países avanzados (el NICE es un magnífico ejemplo). Se
debería además introducir el uso tutelado para determinadas innovaciones
tecnológicas, de manera que pudiera compatibilizarse el estímulo a la innovación
con el riesgo de consumo excesivo no compensado por el incremento en
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34
eficiencia que asume el pagador público.
Capítulo IV
LA PROFESIÓN MÉDICA. EL MÉDICO QUE NECESITAMOS
IV.1
Responsabilidad, compromiso y valores: la crisis de la fragmentación y
tecnificación deshumanizada de la práctica médica
Un
ejercicio de la profesión médica acorde con los tradicionales
principios hipocráticos
y con los que conforman el denominado “nuevo
profesionalismo” supone compromiso con la honestidad en la utilización del
conocimiento y en la optimización de los recursos, con la compasión como guía
de acción frente al sufrimiento, con la mejora permanente en el desempeño
profesional para garantizar la mejor asistencia posible al ciudadano y la
colaboración con todos los profesionales e instituciones sanitarias en aras de la
mejora de salud y el bienestar de la población.
La prestación de servicios por parte del profesional médico no es gratuita.
Genera costes de manera directa e indirecta que, dependiendo del ámbito y
modelo sanitario, debe afrontar el paciente, una compañía de seguros o el
Estado. En este contexto en el que la eficiencia se entiende como la manera de
conseguir los resultados perseguidos al menor coste posible, no podemos eludir
la implicación profesional del médico. La responsabilidad en el ejercicio de la
medicina moderna no puede considerarse como un asunto aislado dentro de la
relación médico-paciente, sino que tiene una dimensión social que trasciende a la
misma siendo esta dimensión uno de los elementos más novedosos del nuevo
profesionalismo médico
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exige comprender la génesis de un modo de ejercer la profesión en el SNS de la
35
El ejercicio riguroso del nuevo profesionalismo es tarea difícil y su logro
España de hoy que resulta ser el fruto de un triple y venturoso desarrollo
científico y social:
1. Un
espectacular
crecimiento
de
las
posibilidades
diagnosticas
y
terapéuticas fruto del desarrollo científico y tecnológico de los últimos
treinta años.
2. La incorporación efectiva de dichas posibilidades a un dispositivo
asistencial universal y público a través de una
mismo
de recursos materiales y humanos
creciente asignación al
junto a modificaciones
organizativas acordes con los imperativos tecnológicos.
3. La consolidación y extensión de un modelo de formación de especialistas
(MIR)
de alto contenido técnico que además ha condicionado en gran
medida la orientación de la formación pregraduada.
Aunque todos, ciudadanos y profesionales, calificamos como básicamente
exitoso y positivo el resultado alcanzado no debemos ignorar la aparición de
algún efecto colateral indeseado cuya existencia pone de manifiesto carencias
graves en el cumplimiento de los compromisos del nuevo (y viejo)
profesionalismo además de amenazar seriamente la legitimidad y sostenibilidad
del propio sistema.
Los mismos tres vectores de desarrollo mencionados han determinado la
emergencia del fenómeno de la hiperespecialización
y su corolario, la
fragmentación del proceso asistencial. La híper-especialización
medicina y su
divide
la
ejercicio en porciones menores sin aportar mecanismos de
coordinación e integración, lo que a su vez provoca la búsqueda estimulada de
pacientes que se puedan beneficiar de ese conocimiento hiperespecializado.
Ambas consecuencias aumentan las necesidades de recursos humanos y técnicos,
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añadiendo el riesgo de descoordinación de terapias y terapeutas.
36
más médicos y medios diferenciados para atender a un único paciente o proceso
En paralelo con el fenómeno de la fragmentación, ha discurrido un modo
de ejercicio profesional centrado casi exclusivamente en la dimensión orgánicobiológica del binomio salud-enfermedad, más empeñado en identificar y corregir
desviaciones de la “normalidad” biológica que en lograr el bienestar mas
razonablemente alcanzable de cada paciente en su circunstancia personal y social
específica
Tales modos de ejercicio de la medicina no responden con suficiencia en
calidad y condiciones al modelo de profesional que defiende la profesión
médica, ni tampoco a los compromisos fijados por el contrato social tácito o
expreso que mantiene ante los ciudadanos. El paciente y su enfermedad son
únicos y único y personalizado debería ser el proceso asistencial con el que se le
atiende. Sin embargo
la amplia disponibilidad de
terapéuticos y especialistas unida a deficiencias
métodos diagnóstico-
formativas y organizativas
ocasionan con gran frecuencia una asistencia fragmentada e inapropiada. El
paciente y su proceso asistencial se mueven a lo largo de una cadena
interdisciplinar (con eslabones a menudo innecesarios) en la cual, la debida
dirección unitaria y coordinación entre los distintos especialistas y niveles
asistenciales son palmariamente
inexistentes. Si este fenómeno fue siempre
rechazable, hoy resulta simplemente inaceptable al constituir el paciente mayor,
crónico y pluripatológico, el usuario hegemónico del SNS más vulnerable que
nadie a las consecuencias de
un
funcionamiento asistencial pensado para
episodios agudos y no para largas vidas con padecimientos crónicos.
La extensión y crecimiento inercial del modelo vigente (mayor
fragmentación, mas consultas y derivaciones, mas especialistas, más tecnología)
es además de económicamente inviable, médicamente indeseable. Se impone
pues el fomento decidido de un cierto neogeneralismo humanista e integrador
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avanzados. Ello implica actuaciones estructurales y organizativas ya señaladas en
37
tal como se está propiciando (o conservando) en países con sistemas sanitarios
el capítulo anterior (Capitulo III) pero sobre todo un cambio cultural en el seno
de la profesión médica que conforme el médico que necesitamos modificando
profundamente el estilo de práctica profesional
IV. 2 La formación del médico que la sociedad necesita
Un ajuste de roles y aptitudes profesionales como el que demanda el
cambio cultural propuesto supone en primer lugar modificar y/o reorientar la
formación médica, tanto en el nivel de grado/licenciatura como en el de la
formación postgraduada (MIR) y sobre todo, por la necesaria inmediatez de
efectos, en la continuada.
Ello implica además de la adquisición y actualización de conocimientos,
habilidades y competencias necesarias (que por cierto van más allá de los
elementos tecnobiológicos), la internalización y renovación de los valores y
creencias que conforman la identidad profesional. Es preciso integrar la
dimensión de economía de la salud por parte de los profesionales sanitarios.
Urge interiorizar que los recursos son escasos y la demanda (en un país como el
nuestro donde el coste en el momento de recibir asistencia es cero) ilimitada, que
cuanto mayor es el progreso médico, mayor es el coste de obtener mejoras
adicionales, que si los recursos son escasos, estamos obligados a buscar la mejor
forma de gastarlos, y que existe un coste de oportunidad en las decisiones que
tomamos día a día en condiciones de incertidumbre. Y todo esto sin dejar de
tener presente que ante todo tenemos un SNS donde prima la equidad.
Por otro lado, el desarrollo académico de la bioética ha prestado escasa
atención a la formación del los futuros profesionales en el compromiso, la
responsabilidad y la perspectiva humanista del concepto salud-enfermedad. La
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toma de decisiones problemáticas en la práctica clínica y en áreas de debate
38
ética de las profesiones sanitarias en las últimas décadas se ha focalizado en la
(cuestiones éticas al comienzo y al final de la vida). El respeto a la autonomía del
paciente se ha inculcado a menudo desde una perspectiva legalista (documentos
de consentimiento informado y de voluntades anticipadas) de tal modo que la
norma está venciendo al espíritu de la ley. En la práctica de la docencia de las
Facultades de Medicina se ha instaurado una dicotomía entre técnica y ética,
como si fueran orbitas separadas
que pueden encontrarse ocasionalmente
cuando hay conflictos olvidando que “técnica” en medicina es sobre todo
práctica clínica, concepto que necesariamente incorpora dimensiones éticas
No es este el documento en el que se deban pormenorizar propuestas de
contenidos específicos a incluir o modificar en los tres niveles de formación
mencionados pero si indicar que tales acciones exigen reflexión y acción
sincronizada de las autoridades de Sanidad y Educación y las organizaciones
profesionales, con acciones en diferentes ámbitos prestando especial atención a
la siempre olvidada formación continuada. En todo caso la inculcación decidida
del rechazo de la práctica clínica inapropiada (inútil, innecesaria, insegura,
inclemente o insensata) y las propuestas formativas acordes con tal logro habrán
de presidir la orientación de los cambios dirigidos a formar y mantener ese
médico del futuro que tan acertadamente ha dibujado con diez rasgos
Fundación
para
la
Educación
Médica
en
la
2009
(http://blogderozman.wordpress.com/page/2).
Es oportuno señalar aquí que al menos en el ámbito de la formación
postgraduada se ha iniciado el camino del cambio en la dirección correcta con el
inminente Decreto de Troncalidad de especialidades médicas que apuesta por un
médico con una formación troncal común integradora que lo hace mas
polivalente y versátil.
Igualmente oportuna y necesaria resulta una
redefinición de roles y
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espacio que debe, liberando al médico de la realización de tareas que consumen
39
responsabilidades profesionales en la que la enfermería y otro personal ocupe el
un valiosísimo tiempo que hoy no puede aplicar a aquello que le es propio e
intransferible.
IV. 3 Necesidades de médicos
Esbozadas las líneas generales relativas al tipo de médico que necesitamos
convendrá hacer un ejercicio estimativo acerca de necesidades de médicos y
especialistas.
Es tarea compleja ya que además de las consideraciones relativas a la
demografía médica
que hasta ahora se han tenido en cuenta (casi
exclusivamente) se deberá contar con al menos dos escenarios futuros
Hemos de imaginar un nuevo escenario en el que el médico generalista
(atención primaria, internista, geriatra) ocupe un mayor espacio y
capacidad resolutiva junto a un especialista dotado de mayor versatilidad
sin olvidar que nuevos avances
tecnológicos demandarán en el otro
extremo del proceso asistencial profesionales superespecializados con
capacitación específica para tareas complejas muy concretas
Asimismo la señalada redefinición de roles profesionales condicionará
enormemente la estimación de necesidades de médicos
De no hacerlo así nuevas estimaciones basadas en la suposición de un
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40
escenario como el actual volverán a ser erróneas.
PROPUESTAS
1. Necesidad de un Acuerdo político
Los médicos consideramos que se necesita urgentemente un Acuerdo político al
máximo nivel que facilite la imprescindible y, desde hace años, postergada,
reforma del SNS, de manera que se garantice su solvencia y no sólo se evite la
vulnerabilidad con que se enfrenta en la actualidad a la profunda crisis
económica en la que el país se encuentra sumido, sino que habilite a la sanidad
pública como una institución robusta e independiente, capaz de ofrecer servicios
de la máxima calidad y eficiencia de cara al futuro. Para ello:
a) Este Acuerdo debe promover un mayor protagonismo profesional en los
niveles estratégicos de decisión,
lo que creemos impedirá que se
instrumentalice la gestión por intereses partidistas y se malgasten energías
en enfrentamientos estériles, que sólo sirven para confundir a la
población, en los que se lanzan propuestas no avaladas por evidencia
alguna que justifique su idoneidad.
b) Así mismo, debe servir para liberar las enormes potencialidades del
Sistema y sus agentes, ahora encorsetadas en un entramado burocrático
muy desincentivador, y ha de contribuir a facilitar la creación de
estructuras de gobierno estables y profesionales, en las que exista una
clara identificación de responsabilidades acompañada de mecanismos de
evaluación y control totalmente transparentes.
Consideramos así mismo que si la frustrante incapacidad de alcanzar
acuerdos se mantuviera, los médicos primaríamos la colaboración con las
formaciones políticas que suscriban los planteamientos expresados en este
Página
41
documento.
2. Establecer
Establecer políticas que garanticen una financiación sanitaria estable y
equilibrada para los distintos servicios de salud de las CCAA:
a) No parece fácil (ni realista) aceptar el retroceso de la financiación sanitaria
pública al 5,1% del PIB en 2015 (como establece el actual Programa de
Estabilidad del Reino de España 2012-2015). Sin que quepa hablar de un
porcentaje correcto, parece que las aspiraciones de una sanidad de calidad
para todos los españoles no es compatible si nos situamos muy por
debajo del 6,5% del PIB:
PIB la media de la OCDE era de 6,9 en 2009
(Health at a Glance, OECD, 2011).
b) Para garantizar una financiación territorial más justa, debería promoverse
una modificación de la financiación autonómica,
autonómica que determinara y
delimitara el gasto sanitario público y lo protegiera con una estimación de
un “per cápita”, ajustado por necesidad, recalculado periódicamente para
cambios demográficos, y con un fondo de compensación o garantía
asistencial para la atención prestada a residentes de otras CCAA. La
tecnología disponible ayuda a gestionar sistemas de compensación, y éstos
evitan tentaciones de insolidaridad o limitación del esfuerzo asistencial.
Finalmente, se precisaría mantener y ampliar un fondo de cohesión para
nivelar las oportunidades de salud de la población y para incentivar las
inversiones que respondan a criterios técnicos de necesidad.
3. Promover el Buen Gobierno en el SNS, a través de medidas legales y técnicas
que aborden los problemas estructurales.
a) Dotar al SNS de un marco legal claro y actualizado,
actualizado refundiendo las leyes
Página
ciudadanía sanitaria, Sistema Nacional de Salud, y sus órganos de
42
y normas anteriores, y estableciendo en positivo el concepto de
gobierno y gestión.
b) Promover en paralelo y para las funciones técnicas de colaboración de los
Servicios Regionales de Salud de las CCAA, una estructura agencial con
bajo nivel de politización, alto nivel de transparencia, que combine
centralidad estratégica y técnica, con estructuración en base a redes
territoriales y que tenga una clara vocación de articular los instrumentos
de gestión de recursos, de personas, de conocimiento y de información,
que constituyen la plataforma de acción compartida del SNS.
c) De igual manera habrá que poner en marcha, utilizando las estructuras y
capacidades existentes, una institución profesional e independiente que
contribuya a evitar intervenciones asistenciales que no aporten valor al
paciente y soporte la actividad de los profesionales con información
objetiva, actualizada y debidamente contrastada.
4. Buen
Buen Gobierno y Buena Gestión en Centros y Servicios sanitarios públicos.
a) Avanzar en la creación de órganos colegiados de gobierno y en la
profesionalización de la gestión:
gestión el “Decálogo para el Buen Gobierno de
los centros sanitarios y la profesionalización de la dirección“, documento
de 2005 que promovió la OMC junto con SESPAS y SEDISA, sigue siendo
plenamente vigente, y, salvo algunas iniciativas aún no consolidadas (País
Vasco), continúan siendo propuestas escasamente atendidas por los
responsables políticos e institucionales.
Página
43
https://www.cgcom.es/sites/default/files/05_03_16_buen_gobierno_0.pdf
b) Promover un rediseño de los servicios públicos de salud: que facilite la
acción integrada entre niveles asistenciales; que permita reconducir la
excesiva fragmentación asistencial; que restaure el enfoque integral y
longitudinal a la persona enferma; que potencie decididamente a la
atención primaria y su papel de gestor clínico de red; que ordene el
territorio para racionalizar tanto los servicios de proximidad como los de
alta especialización; que ponga en marcha estrategias para pacientes
crónicos, pluripatológicos y terminales;
y que vaya aportando
instrumentos de gestión a los centros y servicios, para que puedan
promoverse modelos efectivos de gestión clínica.
5. Profesionalismo y creación de capital clínico, ético y gestor en las profesiones
sanitarias.
a) Un contrato social renovado con las profesiones sanitarias:
sanitarias porque es la
cultura, no la economía, la que garantizará la sostenibilidad de los
sistemas públicos de salud. Para ello son necesarios múltiples cambios, en
la formación, en el desarrollo profesional, y en la gestión del factor
humano profesional. Este es un reto para el cual el SNS debería abrir un
espacio de reflexión claro y vinculante. Las nuevas generaciones de
médicos y especialistas deberían participar desde el inicio en el debate
sobre los retos éticos y organizativos que hoy plantea trabajar en la
moderna medicina y en los sistemas sanitarios público.
b) Un pacto para gestionar la crisis sin descapitalizar la medicina:
medicina formar a un
facultativo es muy caro y consume mucho tiempo; la disminución de la
sanidad pública por recortes en contrataciones, puede dejar a varias
cohortes de médicos y enfermeras fuera del empleo durante varios años,
Página
Los médicos proponemos una reflexión conjunta con las autoridades
44
mientras que la edad media de las plantillas de los centros aumenta.
sanitarias, cabría contemplar un compromiso: a cambio de no reducir en el
empleo joven de médicos,
médicos promover activamente el ahorro en el gasto sanitario,
incluidas reducciones razonables y temporales de la masa salarial. Para ello se
precisaría avanzar en la agenda del Buen Gobierno, la autonomía responsable de
la gestión, y la restauración de la confianza entre las partes, que ha quedado muy
erosionada con la compulsión de acciones unilaterales de recorte.
Han redactado este documento:
documento:
Ignacio Burgos
Enrique Castellón
José Conde Olasagasti
Ricard Gutiérrez Martí
Francisco Hernansanz
Julio Mayol
José Ramón Repullo
Luciano Vidan
45
Enrique Bernal
Médico de AP, Cátedra de Profesionalismo y Ética Clínica
de la Universidad de Zaragoza.
Unidad de Investigación en Políticas y Servicios de SaludARiHSP. Centro de Investigación Biomédica de Aragón.
Zaragoza.
Médico de AP en Ávila.
Vicepresidente del Colegio de Médicos de A Coruña.
Jefe del Servicio de Nefrología. Hospital Virgen de la
Salud. Toledo
Vicepresidente del Consejo General de Colegios Oficiales
de Médicos.
Subdirector de la Cátedra de Medicina de Familia y
Economía de la Salud. Universitat Pompeu Fabra.
Barcelona.
Jefe Sección Cirugía Digestiva del Hospital Clínico San
Carlos. Madrid
Jefe Departamento de Planificación y Economía de la
Salud. Escuela Nacional de Sanidad. Madrid.
Presidente del Colegio Oficial Médicos de A Coruña.
Página
Rogelio Altisent
Foro de la Profesión
Médica de España
EL FORO DE LA PROFESIÓN MÉDICA EXIGE LA SOLUCIÓN
INMEDIATA A LA SITUACIÓN ACTUAL DE LA SANIDAD DE LA
COMUNIDAD DE MADRID
• En su reunión de hoy, el Foro de la Profesión Médica también ha
ratificado la propuesta de la Organización Médica Colegial relativa a
la convocatoria consensuada de una Manifestación en Madrid,
prevista para el próximo 23 de febrero
• Además, se ha acogido otra propuesta
por parte de la
Confederación Estatal de Sindicatos Médicos (CESM), consistente
en promover movilizaciones por toda España
El Foro de la Profesión Médica es consciente de la grave crisis económicofinanciera que atraviesa nuestro país. Sin embargo, considera que las medidas
de ajustes presupuestarios que están afectando a la Sanidad madrileña no
justifican, en ningún caso, las formas que el Gobierno de la Comunidad de
Madrid (CAM) ha empleado para plantear dichas medidas que el Foro
considera absolutamente desproporcionadas, que ponen en riesgo la calidad
de los servicios sanitarios, y que se implementan sin la participación de los
profesionales.
El Foro de la Profesión Médica considera que la respuesta que todos los
profesionales han dado a las medidas planteadas por el Gobierno de la CAM
ha sido absolutamente coherente y adecuada. Respuesta a la que se han
sumado muchos ciudadanos y en la que destaca el alto grado de compromiso
con la sociedad y con la calidad de la asistencia sanitaria.
Es por ello que ante la grave situación planteada en estos momentos, el Foro
de la Profesión Médica ha acordado en su reunión de hoy, 13 de diciembre,
celebrada en la sede de la OMC, instar a todas las partes a que se sienten a
dialogar y a que se intente llegar a un acuerdo que dé solución inmediata a
esta problemática.
El Foro de la Profesión Médica se ofrece, asimismo, como mediador entre las
partes para intentar que este acuerdo o solución inmediata se adopte a la
mayor brevedad.
OMC - FACME - CESM - CNDFM - CNECS - CEEM
Foro de la Profesión
Médica de España
CONVOCATORIA DE MANIFESTACIÓN
En su reunión de hoy, el Foro de la Profesión Médica también ha ratificado la
propuesta de la Organización Médica Colegial (OMC), acordada en Asamblea
Extraordinaria y Urgente del pasado 17 de noviembre,
relativa a la
convocatoria consensuada de una Manifestación en Madrid, como signo de
expresión de la unidad del colectivo médico ante la actual situación del Sistema
Nacional de Salud.
Dicha acción, prevista para el próximo sábado 23 de febrero de 2013, tiene
como finalidad, por un lado, la defensa a ultranza del SNS y, por otro, el
rechazo unánime a las medidas indiscriminadas que afecten a la calidad de la
asistencia y a la buena praxis tanto a nivel del Estado como de las
Comunidades Autónomas.
MOVILIZACIONES POR TODA ESPAÑA
En la misma sesión de hoy, se ha acogido otra propuesta por parte de la
Confederación Estatal de Sindicatos Médicos (CESM), que ha sido valorada
positivamente por parte del Foro de la Profesión Médica, consistente en
promover movilizaciones por toda España, que sean aprobadas en el Comité
Ejecutivo de CESM, previsto para el 9 de enero, y en la Plataforma de Unidad
de Acción Médica, constituida por la OMC, FACME y CESM, que se reunirá el
próximo 8 de enero, y que contará con la presencia, a su vez, de los
estudiantes de Medicina, representados por su Consejo Estatal (CEEM).
Para más información contactar con el portavoz del Foro de la Profesión
Médica:
-Dr. Francisco Miralles (CESM) Telf: 610 280 441
OMC - FACME - CESM - CNDFM - CNECS - CEEM
CONSEJO GENERAL DE COLEGIOS OFICIALES DE MÉDICOS
La OMC presenta a Núñez Feijoo un
documento de propuestas de reforma
sanitaria
Es un documento “crítico”, con propuestas reales y
compromiso de los profesionales para la sostenibilidad
del SNS
5 propuestas: acuerdo político, financiación estable,
Buen Gobierno en el SNS, buena gestión en centros y
servicios y un contrato social renovado con los
sanitarios
Los médicos se comprometen a promover el ahorro del
gasto a cambio de no reducir el empleo de jóvenes
La OMC considera una oportunidad contar con la
interlocución de un Gobierno sensible como el de la
Xunta
La Organización Médica Colegial (OMC) ha presentado hoy
al Presidente de la Xunta de Galicia, Alberto Núñez Feijoo,
un documento de propuestas de reforma sanitaria para una
acción inmediata que garanticen la sostenibilidad del
Sistema Nacional de Salud.
El documento titulado “Profesión Médica y Reforma
Sanitaria” fue entregado hoy a Alberto Núñez Feijoo por el
presidente de la OMC, Juan José Rodríguez Sendín, en un
encuentro celebrado en la Xunta de Galicia, en el que
estuvieron presentes también la Conselleira de Sanidad,
Rocío Mosquera, y los presidentes de los colegios médicos
de A Coruña, Luciano Vidan y Ourense, Pedro Trillo.
1
Este documento, que ha sido elaborado por diez
profesionales, la mayor parte de los cuales no ostenta
representación institucional alguna y muchos de ellos
tienen actividad clínica asistencial, responde a una petición
del Presidente de la Xunta de Galicia al presidente de la
OMC para conocer el punto de vista de la profesión
médica en relación a las tensiones por las que está
atravesando la sanidad pública en España.
Los 10 profesionales que, durante dos meses, han
elaborado este documento son: Rogelio Altisent, médico de
AP, director de la Cátedra de Profesionalismo y Ética
Clínica de la Universidad de Zaragoza; Enrique Bernal,
Unidad de Investigación en Políticas y Servicios de SaludARiHSP. Centro de Investigación Biomédica de Aragón.
Zaragoza; Ignacio Burgos, médico de AP en Ávila; Enrique
Castellón, vicepresidente del Colegio de Médicos de A
Coruña; José Conde Olasagasti, Jefe del Servicio de
Nefrología. Hospital Virgen de la Salud. Toledo; Ricard
Gutiérrez Martí, vicepresidente del Consejo General de
Colegios Oficiales de Médicos; Francisco Hernansanz,
médico de AP, subdirector de la Cátedra de Medicina de
Familia y Economía de la Salud. Universitat Pompeu Fabra.
Barcelona; Julio Mayol, Jefe de Sección de Cirugía
Digestiva del Hospital Clínico San Carlos. Madrid; José
Ramón Repullo, jefe Departamento de Planificación y
Economía de la Salud. Escuela Nacional de Sanidad.
Madrid, y Luciano Vidan, presidente del Colegio Oficial
Médicos de A Coruña.
El documento de la OMC considera que “la respuesta
sostenible y eficiente a la crisis financiera en la sanidad,
exige cambios estructurales y de estrategias” pero expone
que “los recortes lineales bloquean estos cambios e
imponen reducciones que no sólo afectan a lo prescindible
2
si lo hubiera, sino que también a lo imprescindible para
mantener la calidad de los servicios sanitarios”.
Considera que “la única forma de hacer economías
selectivas que promuevan la sostenibilidad interna del
Sistema Nacional de Salud es revitalizando la alianza con
los profesionales y utilizando instrumentos de gestión y
gobierno clínico”.
No obstante, la Organización Médica Colegial afirma en el
documento que su posición es inequívoca: “toca hablar y
buscar soluciones reales” y “comprometerse en su puesta
en práctica”.
En la base de todas las propuestas efectuadas late la
“exigencia de dar un protagonismo efectivo y de mayor
alcance a la profesión médica y estudiar las fórmulas más
eficaces para que ese liderazgo exista realmente y no
provoque desconfianza ni impida la fluidez en la toma de
decisiones” y cuestiona la multiplicación de órganos
asesores en los que intervienen los médicos que “apenas
son escuchados y, como mucho, reciben algunas
explicaciones”.
En la presentación del documento, se destaca que algunas
administraciones como la de la Xunta de Galicia, han
“maniobrado con acierto” para acotar los efectos negativos
de algunas medidas y han llevado a cabo valiosas
iniciativas, destacando la de la Xunta de introducir mayor
racionalidad en el uso de los medicamentos, hasta un
mayor esfuerzo por adoptar un enfoque más sensible con
las necesidades de la profesión, por todo lo cual, la OMC
considera “una oportunidad contar con la interlocución de
un Gobierno sensible y confía en la generalización de esta
actitud”.
3
Se trata de un documento “crítico” en el que los médicos
delimitan las “líneas rojas” que no deben sobrepasarse en
esta situación de crisis y realizan sus propuestas para la
sostenibilidad del SNS.
Son 5 propuestas básicas son:
1º- La necesidad de un acuerdo político para la reforma del
SNS que garantice su solvencia y que promueva un mayor
protagonismo profesional en los niveles estratégicos de
decisión para impedir que se instrumentalice la gestión por
intereses partidistas.
2º) Una financiación estable y equilibrada para los distintos
servicios de salud de las CCAA que determine y delimite el
gasto sanitario público y lo protegiera con una estimación
“per cápita”, ajustado por necesidad y recalculado
periódicamente para cambios demográficos.
3º.-Promoción del Buen Gobierno del SNS a través de
medidas legales y técnicas que aborden los problemas
estructurales, entre ellas, un marco legal actualizado, una
estructura agencial con bajo nivel de politización y alto nivel
de trasparencia, y una institución profesional independiente
que contribuya a evitar intervenciones asistenciales que no
aporten valor al paciente y soporte la actividad de los
profesionales con información objetiva, actualizada y
debidamente contrastada.
4º.-Buen Gobierno y Buena Gestión en Centros y Servicios
Sanitarios Público, avanzando en la creación de órganos
colegiados de gobierno y en la profesionalización de la
gestión, así como promover un rediseño de los servicios
públicos de salud. En el documento se pone de manifiesto
que el “Decálogo para el Buen Gobierno de los centros
sanitarios y la profesionalización de la dirección” promovido
por la OMC junto con SESPAS y SEDISA sigue siendo
plenamente vigente.
5º.-Profesionalismo y creación de capital clínico, ético y
gestor en las profesiones sanitarias que abarca un contrato
4
social renovado con las profesiones sanitarias porque
consideran que “es la cultura y no la economía, la que
garantizará la sostenibilidad de los sistemas públicos de
salud” y un pacto para gestionar la crisis sin descapitalizar
la medicina.
Finalmente, propone una reflexión conjunta con las
autoridades sanitaria y el compromiso de “promover
activamente el ahorro en el gasto sanitario” a cambio de no
reducir en el empleo joven de médicos para lo cual se
precisaría “avanzar en la agenda del Buen Gobierno, la
autonomía responsable de la gestión y la restauración de la
confianza entre las partes que ha quedado muy erosionada
con la compulsión de acciones unilaterales de recorte”.
5
El secretario general de la OMC solicita a
Echániz una rectificación inmediata
El secretario general de la OMC, Serafin Romero, ha
solicitado al Consejero de Sanidad de Castilla la Mancha,
José Ignacio Echániz, una rectificación inmediata de sus
declaraciones en relación a las “peonadas” en las que pone
de manifiesto graves acusaciones contra los profesionales
médicos a los que acusa de “realizar intervenciones
innecesarias” a cambios de emolumentos económicos.
• Ante las declaraciones del Consejero de Castilla la
Mancha D. José Ignacio Echániz, que el miércoles dijo
textualmente que los datos demuestran que los niveles
de rendimiento en jornada de mañana eran muy
inferiores a los de jornada de tarde e incluso ha apuntado
que se “operaba a un número de personas por encima de
los estándares de otros centros de otras comunidades
autónomas” y con “indicaciones quirúrgicas por encima
de lo necesario”, desde la corporación “solicitamos que
se aclaren los términos referidos que, aunque pudiera
entrar en una lógica de la variabilidad de la práctica
clínica que se da en la profesión médica y en todos los
ámbitos asistenciales, dejan entrever un tono acusador
sobre posibles prácticas constitutivas de delito y
realizadas sobre ciudadanos sin posible indicación para
ello”.
• Para el doctor Romero, estas desafortunadas
declaraciones que se realizan en una situación grave de
nuestro SNS se dirigen contra la profesión médica en
1
general, sin definir quién, quienes y en donde se
producen estas irregularidades, dejando entrever que la
situación por la que atraviesa la sostenibilidad del modelo
sanitario que tantas satisfacciones nos ha dado es
debida a una mala práctica de todos los profesionales de
la medicina.
• Según el secretario general de la OMC, detrás de estas
acusaciones contra los médicos, se encuentra también
toda una grave acusación contra todos los Gerentes de
las Instituciones Sanitarias de Castilla la Mancha que
parece que ha estado mirando hacia otro lado y que son
coparticipes por su ineficiencia e incompetencia, junto
con los profesionales, de la gravísima situación de la
Sanidad especialmente en esta Comunidad Autónoma.
• Asegura que la sorpresa ha sido mayor tras haberse
valorado positivamente el cambio de rumbo en las
relaciones entre Consejería y profesionales con el
objetivo de seguir dando a todos los ciudadanos de
Castilla la Mancha una atención de calidad y sostenible,
por lo que pide una rectificación inmediata de las citadas
declaraciones.
2
Health at a Glance
Europe 2012
Health at a Glance:
Europe 2012
This work is published on the responsibility of the Secretary-General of the OECD.
The opinions expressed and arguments employed herein do not necessarily reflect the
official views of the OECD or of the governments of its member countries or those of the
European Union.
This document and any map included herein are without prejudice to the status of or
sovereignty over any territory, to the delimitation of international frontiers and boundaries
and to the name of any territory, city or area.
Please cite this publication as:
OECD (2012), Health at a Glance: Europe 2012, OECD Publishing.
http://dx.doi.org/10.1787/9789264183896-en
ISBN 978-92-64-18360-5 (print)
ISBN 978-92-64-18389-6 (HTML)
Series: Health at a Glance: Europe
ISSN 2305-607X (print)
ISSN 2305-6088 (online)
European Union
Catalogue number: ND-32-12-458-EN-C (print)
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FOREWORD
Foreword
T
his second edition of Health at a Glance: Europe presents the most recent key indicators of
health and health systems across 35 countries: the 27 European Union member states, five
candidate countries and three European Free Trade Association countries. The report comes at a
difficult time for European health systems. The economic crisis is increasing poverty, unemployment
and stress, all of which are associated with worse health outcomes, yet public and private budgets
are under great strain. The report highlights the marked slowdown (sometimes even reduction) in
health spending over recent years in many countries, as part of broader efforts to reduce large
budgetary deficits. If the report does not yet show any worsening health outcomes due to the crisis,
there is no cause for complacency – it takes time for poor social conditions or poor quality care to take
its toll from people’s health. Policy makers have often done what they could to ensure that access to
high quality care remains the norm in Europe; whether this is enough to protect the health of the
population will only become clear in years to come.
The indicators presented in this report are based largely on the European Community Health
Indicators (ECHI), a set of indicators used by the European Commission to guide the development of
health information systems in Europe. Additional indicators examine health expenditure trends as
well as quality of care, building on OECD expertise in these domains.
The publication at hand reflects the long and fruitful collaboration between the OECD and the
European Commission in the development and reporting of health statistics. Since 2005, a joint data
collection between the OECD, the European Commission and the World Health Organization has
improved the availability of comparable data on health expenditure, based on a common System of
Health Accounts. Furthermore, since 2010, these three organisations have gathered additional data on
the health workforce as well as on the physical and technical resources required to deliver health services.
The OECD and the European Commission will continue to work closely together to improve the
quality and comparability of data to monitor population health and the performance of health
systems across European countries.
In the meantime, we hope that this publication will be useful to you and that it will stimulate
action to improve the health of European citizens by learning from each others’ experience.
Yves Leterme
Deputy Secretary-General
Organisation for Economic Co-operation
and Development
HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012
Paola Testori Coggi
Director-General
Directorate-General for Health and Consumers
European Commission
3
ACKNOWLEDGEMENTS
Acknowledgements
T
his publication would not have been possible without the effort of national data
correspondents from the 35 countries who have provided most of the data and the
metadata presented in this report. The OECD and the European Commission would like to
sincerely thank them for their contribution.
This report was prepared by a team from the OECD Health Division under the
co-ordination of Gaétan Lafortune and Michael de Looper. Chapter 1 and Chapter 2 were
prepared by Michael de Looper; Chapter 3 by Gaétan Lafortune and Gaëlle Balestat;
Chapter 4 by Kees van Gool and Nelly Biondi, under the supervision of Niek Klazinga; and
Chapter 5 by Michael Mueller and David Morgan.
A large part of the data presented in this publication come from the two annual data
collections on health accounts and non-monetary health care statistics carried out jointly
by the OECD, Eurostat and WHO. It is important to recognise the work of colleagues from
Eurostat (Elodie Cayotte) and WHO Europe (Ivo Rakovac and Natela Nadareishvili) who
have contributed to validating some of the data presented in this publication, to ensure
that they meet the highest standards of quality and comparability.
The OECD would also like to recognise the contribution of Mika Gissler, from the
National Institute for Health and Welfare in Finland and the leader of the former Joint Action
on the European Community Health Indicators Monitoring project, for providing useful
guidance and advice on the content of this publication. Thanks also go to Jürgen Thelen from
the Robert Koch Institute for assistance with data on adult fruit and vegetable consumption,
and Jean-Marie Robine and Carol Jagger (European Joint Action on Healthy Life Years: EHLEIS)
for their contribution on the healthy life years indicator.
This publication benefited from comments from Mark Pearson (Head of OECD Health
Division). Many useful comments were also received from Stefan Schreck, Boriana Goranova
and Fabienne Lefebvre from the European Commission (DG SANCO, Health Information
Unit), as well as from officials in other DG SANCO Units.
4
TABLE OF CONTENTS
Table of contents
Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
Chapter 1.
Health status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15
1.1. Life expectancy and healthy life expectancy at birth. . . . . . . . . . . . . . . . . . . . .
1.2. Life expectancy and healthy life expectancy at age 65 . . . . . . . . . . . . . . . . . . .
1.3. Mortality from all causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.4. Mortality from heart disease and stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.5. Mortality from cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.6. Mortality from transport accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.7. Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.8. Infant mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.9. Infant health: Low birth weight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.10. Self-reported health and disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.11. Incidence of selected communicable diseases . . . . . . . . . . . . . . . . . . . . . . . . . .
1.12. HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.13. Cancer incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16
18
20
22
24
26
28
30
32
34
36
38
40
1.14. Diabetes prevalence and incidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.15. Dementia prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.16. Asthma and COPD prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42
44
46
Chapter 2.
2.1.
2.2.
2.3.
2.4.
2.5.
2.6.
2.7.
2.8.
Chapter 3.
3.1.
3.2.
3.3.
3.4.
3.5.
3.6.
3.7.
3.8.
Determinants of health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
49
Smoking and alcohol consumption among children . . . . . . . . . . . . . . . . . . . . .
Overweight and obesity among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fruit and vegetable consumption among children. . . . . . . . . . . . . . . . . . . . . . .
Physical activity among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Smoking among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alcohol consumption among adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Overweight and obesity among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fruit and vegetable consumption among adults . . . . . . . . . . . . . . . . . . . . . . . .
50
52
54
56
58
60
62
64
Health care resources and activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
67
Medical doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Consultations with doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical technologies: CT scanners and MRI units . . . . . . . . . . . . . . . . . . . . . . .
Hospital beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hospital discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Average length of stay in hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cardiac procedures (coronary angioplasty) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
68
70
72
74
76
78
80
82
5
TABLE OF CONTENTS
3.9. Cataract surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.10. Hip and knee replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.11. Pharmaceutical consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.12. Unmet health care needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chapter 4.
84
86
88
90
Quality of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
93
Care for chronic conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1. Avoidable admissions: Respiratory diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2. Avoidable admissions: Uncontrolled diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . .
94
94
96
Acute care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
98
4.3. In-hospital mortality following acute myocardial infarction . . . . . . . . . . . . . .
98
4.4. In-hospital mortality following stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.5. Procedural or postoperative complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.6. Obstetric trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Cancer care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.7. Screening, survival and mortality for cervical cancer . . . . . . . . . . . . . . . . . . . .
4.8. Screening, survival and mortality for breast cancer. . . . . . . . . . . . . . . . . . . . . .
4.9. Screening, survival and mortality for colorectal cancer . . . . . . . . . . . . . . . . . .
106
106
108
110
Care for communicable diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
4.10. Childhood vaccination programmes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
4.11. Influenza vaccination for older people. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Chapter 5.
5.1.
5.2.
5.3.
5.4.
5.5.
5.6.
5.7.
Health expenditure and financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Coverage for health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health expenditure per capita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health expenditure in relation to GDP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Health expenditure by function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pharmaceutical expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Financing of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Trade in health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
118
120
122
124
126
128
130
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Annex A.
Additional information on demographic and economic context . . . . . . . . 143
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6
Health at a Glance: Europe 2012
© OECD 2012
Executive summary
E
uropean countries have achieved major gains in population health in recent decades.
Life expectancy at birth in European Union (EU) member states has increased by more than
six years since 1980, to reach 79 years in 2010, while premature mortality has reduced
dramatically. Over three-quarters of these years of life can be expected to be lived free of
activity limitation. Gains in life expectancy can be explained by improved living and
working conditions and some health-related behaviours, but better access to care and
quality of care also deserves much credit, as shown, for instance, by sharply reduced
mortality rates following a heart attack or stroke.
Many health improvements have come at considerable financial cost. Until 2009, health
spending in European countries grew at a faster rate than the rest of the economy, and the
health sector absorbed a growing share of the gross domestic product (GDP). Following the
onset of the financial and economic crisis in 2008, many European countries reduced health
spending as part of broader efforts to reign in large budgetary deficits and growing debt-to-GDP
ratios. Although these cuts might have been unavoidable, some measures may have an impact
on the fundamental goals of health systems. Continuous monitoring of data and indicators on
health and health systems is therefore important; it provides indications of the potential short
and longer-term impact of changing economic circumstances and health policies on health
care access, quality and health outcomes.
This second edition of Health at a Glance: Europe presents the most recent comparable data for
selected indicators of health and health systems in 35 European countries – the 27 member
states of the European Union, five candidate countries and three EFTA countries – up to 2010.
The selection of indicators has been based on the European Community Health Indicators
(ECHI) shortlist, a list of indicators that has been developed by the European Commission to
guide the development and reporting of health statistics. In addition, the publication provides
detailed information on health expenditure and financing trends, using results from the OECD,
Eurostat and WHO annual joint health accounts questionnaire. It also includes a new chapter
on quality of health care, reflecting the progress achieved under the OECD Health Care Quality
Indicators project. The data presented here come mainly from official national statistics,
collected individually or jointly by the OECD, Eurostat or WHO-Europe, as well as multi-country
surveys such as the Health Behaviour in School-aged Children (HBSC) survey.
Health at a Glance: Europe 2012 presents trends over time and variations across European
countries under five broad topics: 1) population health status; 2) risk factors to health;
3) resources and activities of health care systems; 4) quality of care for chronic and acute
conditions; and 5) health expenditure and financing sources. It offers some explanation for
these variations, providing background for further research and analysis to understand
more fully the causes underlying such variations and to develop policy options to reduce
gaps with those countries that are achieving better results. Many indicators provide a
breakdown by sex and age in each country, and several include a further breakdown by
7
EXECUTIVE SUMMARY
income or education levels. These indicators show that there may be as much variation
within a country by sub-national regions, socio-economic groups or ethnic/racial groups as
there is across countries.
Health status has improved dramatically
in European countries, although large gaps persist
●
Life expectancy at birth in EU member states has increased by over 6 years between 1980
and 2010. On average across the European Union, life expectancy at birth for the three-year
period 2008-10 was 75.3 years for men and 81.7 years for women. France had the highest life
expectancy for women (85.0 years), and Sweden for men (79.4 years). Life expectancy at birth
in the EU was lowest in Bulgaria and Romania for women (77.3 years) and Lithuania for men
(67.3 years). The gap between EU member states with the highest and lowest life
expectancies at birth is around 8 years for women and 12 years for men (Figure 1.1.1).
●
On average across the European Union, healthy life years (HLY) at birth, defined as the
number of years of life free of activity limitation, was 62.2 years for women and
61.0 years for men in 2008-10. The gender gap is much smaller than for life expectancy,
reflecting the fact that a higher proportion of the life of women is spent with some
activity limitations. HLY at birth in 2008-10 was greatest in Malta for women and Sweden
for men, and shortest in the Slovak Republic for both women and men (Figure 1.1.1).
●
Life expectancy at age 65 has also increased substantially in European countries, averaging
16.5 years for men and 20.1 years for women in the European Union in 2008-10. As for life
expectancy at birth, France had the highest life expectancy at age 65 for women
(23.2 years) but also for men (18.7 years). Life expectancy at age 65 in the European Union
was lowest in Bulgaria for women (16.9 years) and Latvia for men (13.2 years) (Figure 1.2.1).
●
Large inequalities in life expectancy persist between socio-economic groups. For both
men and women, highly educated persons are likely to live longer; in the Czech Republic
for example, 65-year-old men with a high level of education can expect to live seven
years longer than men of the same age with a low education level (Figure 1.2.3).
●
It is difficult to estimate the relative contribution of the numerous non-medical and
medical factors that might affect variations in life expectancy across countries. Higher
national income is generally associated with higher (healthy) life expectancy, although
the relationship is less pronounced at the highest income levels, suggesting a
“diminishing return” (Figure 1.1.2).
●
Chronic diseases such as diabetes, asthma and dementia are increasingly prevalent, due
either to better diagnosis or more underlying disease. More than 6% of people aged
20-79 years in the European Union, or 30 million people, had diabetes in 2011 (Figure 1.14.1).
Better management of chronic diseases has become a health policy priority for many
EU member states.
Risk factors to health are changing
●
Most European countries have reduced tobacco consumption via public awareness
campaigns, advertising bans and increased taxation. The percentage of adults who
smoke daily is below 15% in Sweden and Iceland, from over 30% in 1980. At the other end
of the scale, over 30% of adults in Greece smoke daily. Smoking rates continue to be high
in Bulgaria, Ireland and Latvia (Figure 2.5.1).
8
EXECUTIVE SUMMARY
●
Alcohol consumption has also fallen in many European countries. Curbs on advertising,
sales restrictions and taxation have all proven to be effective measures. Traditional
wine-producing countries, such as France, Italy and Spain, have seen consumption per
capita fall substantially since 1980. Alcohol consumption per adult rose significantly in a
number of countries, including Cyprus, Finland and Ireland (Figure 2.6.1).
●
In the European Union, 52% of the adult population is now overweight, of which 17% is
obese. At the country level, the prevalence of overweight and obesity exceeds 50% in 18
of the 27 EU member states. Rates are much lower in France, Italy and Switzerland,
although increasing there as well. The prevalence of obesity – which presents greater
health risks than overweight – ranges from 8% in Romania and Switzerland to over 25%
in Hungary and the United Kingdom (Figure 2.7.1). The obesity rate has doubled
since 1990 in many European countries (Figure 2.7.2). Rising obesity has affected all
population groups, to varying extents. Obesity tends to be more common among
disadvantaged social groups, and especially women.
The number of doctors and nurses per capita
is higher than ever before in most countries,
but there are concerns about current or future
shortages
●
Ensuring proper access to health care is a fundamental policy objective in all EU member
states. It requires, among other things, having the right number of health care providers
in the right places to respond to the population’s needs. There are concerns in many
European countries about shortages of doctors and nurses, although recent public
spending cuts on health in some countries may have led to at least a temporary
reduction in demand.
●
Since 2000, the number of doctors per capita has increased in almost all EU member
states. On average across the European Union, the number of doctors grew from 2.9 per
1 000 population in 2000 to 3.4 in 2010. Growth was particularly rapid in Greece and the
United Kingdom (Figure 3.1.1).
●
In nearly all countries, the balance between generalist and specialist doctors has
changed such that there are now more specialists (Figure 3.1.2). This may be explained
by a reduced interest in traditional “family medicine” practice, combined with a growing
remuneration gap between generalists and specialists. The slow growth or reduction in
the number of generalists raises concerns in many countries about access to primary
care for certain population groups.
●
There are also concerns about possible shortages of nurses, and this may well intensify
in the future as the demand for nurses continues to increase and the ageing of the
“baby boom” generation precipitates a wave of retirements among nurses. Over the past
decade, the number of nurses per capita has increased in nearly all EU member states
(Figure 3.3.1). The increase was particularly large in Demark, France, Portugal and Spain.
However, recently there has been a reduction in nurses employed in some countries
hardest hit by the economic crisis. In Estonia, the number of nurses increased to 2008,
but has decreased since then, with a resulting fall from 6.4 per 1 000 population in 2008
to 6.1 in 2010.
9
EXECUTIVE SUMMARY
Quality of care has improved in most European
countries, though all countries can do better,
particularly to avoid hospital admissions
for people with chronic diseases
●
There has been progress in the treatment of life-threatening conditions such as heart
attack, stroke and cancer in all reporting European countries. Mortality rates following
hospital admissions for heart attack (acute myocardial infarction) have fallen by
nearly 50% between 2000 and 2009 (Figure 4.3.3) and for stroke by over 20% (Figure 4.4.3).
These improvements reflect better acute care and greater access to dedicated stroke
units in countries like Denmark and Sweden.
●
Survival rates for different types of cancer have also improved in most countries, reflecting
earlier detection and greater treatment effectiveness (Figures 4.7.2 and 4.8.2). While survival
rates for breast cancer remain below 80% in the Czech Republic and Slovenia, they have
increased by over 10 percentage points between 1997-2002 and 2004-09. These two countries
also witnessed substantial gains in survival rates for colorectal cancer (Figure 4.9.2).
●
It is more difficult to monitor quality of care in the primary care sector, as in most
countries there are fewer data than in the hospital sector. Avoidable hospital admission is
often used as an indicator of either access problems to primary care or the quality and
continuity of care. There is general consensus that asthma and diabetes should largely be
managed through proper primary care interventions to avoid exacerbation and costly
hospitalisation. While hospital admissions for asthma are low in certain countries, they
are much higher in others, such as the Slovak Republic (Figure 4.1.1). In all European
countries, there are too many hospital admissions for uncontrolled diabetes (Figure 4.2.1).
Growth in health expenditure has slowed or fallen
in many European countries
10
●
Growth in health spending per capita slowed or fell in real terms in 2010 in almost all
European countries, reversing a trend of steady increases. Spending had already started
to fall in 2009 in countries hardest hit by the economic crisis (e.g. Estonia and Iceland),
but this was followed by deeper cuts in 2010 in response to growing budgetary pressures
and rising debt-to-GDP ratios. On average across the EU, health spending per capita
increased by 4.6% per year in real terms between 2000 and 2009, followed by a fall of 0.6%
in 2010 (Figure 5.2.2).
●
Reductions in public spending on health were achieved through a range of measures,
including reductions in wages and/or employment levels, increasing direct payments by
households for certain services and pharmaceuticals, and imposing severe budget
constraints on hospitals. Gains in efficiency have also been pursued through mergers of
hospitals or accelerating the move from inpatient care to outpatient care and day surgery.
●
As a result of the negative growth in health spending in 2010, the percentage of GDP devoted
to health stabilised or declined slightly in many EU member states. In 2010, EU member
states devoted on average 9.0% (unweighted) of their GDP to health spending (Figure 5.3.1),
up significantly from 7.3% in 2000, but down slightly from the peak of 9.2% in 2009.
●
The Netherlands allocated the highest share of GDP to health in 2010 (12%), followed by
France and Germany (both at 11.6%). In terms of health spending per capita, the
Netherlands (EUR 3 890), Luxembourg (EUR 3 607) and Denmark (EUR 3 439) were the
EXECUTIVE SUMMARY
highest spenders among EU member states. Austria, France and Germany followed, at
over EUR 3 000 per capita. Bulgaria and Romania were the lowest spending countries, at
around EUR 700.
●
The public sector is the main source of health care financing in all European countries,
except Cyprus (Figure 5.6.1). In 2010, nearly three-quarter (73%) of all health spending
was publicly financed on average in EU member states. Public financing accounted for
over 80% in the Netherlands, the Nordic countries (except Finland), Luxembourg, the
Czech Republic, the United Kingdom and Romania. The share was the lowest in Cyprus
(43%), and Bulgaria, Greece and Latvia (55-60%).
●
The economic crisis has affected the mix of public and private health financing in some
countries. Public spending has been cut for certain goods and services, often combined with
increases in the share of direct payments by households. In Ireland, the share of public
financing of health spending decreased by nearly 6 percentage points between 2008
and 2010, and stands now at 70%, while the share of out-of-pocket payments by households
increased. There have also been substantial falls in Bulgaria and the Slovak Republic.
●
After public financing, the main source of funding for health expenditure in most
countries is out-of-pocket payments. Private health insurance financing only plays a
significant role in a few countries. In 2010, the share of out-of-pocket payments was
highest in Cyprus (49%), Bulgaria (43%) and Greece (38%). It was the lowest in the
Netherlands (6%), France (7%) and the United Kingdom (9%). Its share has increased over
the past decade in about half of EU member states, most notably in Bulgaria, Cyprus,
Malta and the Slovak Republic (Figure 5.6.3).
●
The economic crisis and growing budgetary constraints have put additional pressures on
health systems in many European countries. Several countries that have been hardest
hit by the crisis have taken a series of measures to reduce public spending on health. It
will be important to monitor closely the short and longer-term impact of these measures
on the fundamental goals of health systems in European countries of ensuring proper
access and quality of care.
11
INTRODUCTION
Introduction
H
ealth at a Glance: Europe 2012 presents key indicators of health and health systems in
35 European countries, including the 27 European Union member states, 5 candidate
countries and 3 European Free Trade Association countries. The selection of indicators is
based largely on the European Community Health Indicators (ECHI) shortlist, a set of
indicators that has been developed to guide the reporting of health statistics in the
European Union (ECHIM, 2012). It is complemented by additional indicators on health
expenditure and quality of care in the related chapters.
The first edition of this report was released in 2010. This second edition includes a
larger number of ECHI indicators (notably in the first chapter on health status and in the
chapter on health care resources and activities), reflecting progress in data availability and
comparability. There is also a new chapter on quality of care combining certain ECHI
indicators with selected indicators on quality of care and patient safety developed under
the OECD Health Care Quality Indicators project (OECD, 2010c).
The data presented in this publication are mostly official national statistics and have
been collected through questionnaires administered by the OECD, Eurostat and WHO. The
data have been validated by the three organisations to ensure that they meet standards of
data quality and comparability. In certain cases, the data come from regular cross-national
surveys, such as the Health Behaviour in School-aged Children surveys for the set of
indicators on health risk factors among children. All indicators are presented in the form
of easy-to-read figures and explanatory text, based on a two-page format per indicator.
Structure of the publication
The publication is structured around five chapters:
12
●
Chapter 1 on Health status highlights the variations across countries in life expectancy
and healthy life expectancy, and also presents other indicators of causes of mortality
and morbidity, including both communicable and non-communicable diseases.
●
Chapter 2 on Determinants of health focuses on non-medical determinants of health
related to modifiable lifestyles and behaviours among children and adults, such as
smoking and alcohol drinking, nutrition, physical activity, and overweight and obesity.
●
Chapter 3 on Health care resources and activities reviews some of the inputs and outputs of
health care systems, including the supply of doctors and nurses, different types of
equipment used for diagnosis or treatment, and the provision of a range of services to
prevent the transmission of communicable diseases or to treat acute conditions.
●
Chapter 4 is a new chapter on Quality of care, providing comparisons on care for chronic
and acute conditions, cancers and communicable diseases. The chapter also includes a
set of indicators on patient safety, building on the developmental work and data
collection carried out under the OECD Health Care Quality Indicators project.
INTRODUCTION
●
Chapter 5 on Health expenditure and financing examines trends in health spending across
European countries, both overall and for different types of health services and goods,
including pharmaceuticals. It also looks at how these health services and goods are paid
for and the different mix between public funding, private health insurance, and direct
out-of-pocket payments by households.
An annex provides some additional tables on the demographic and economic context
within which different health systems operate, as well as additional data on health
expenditure trends.
Presentation of indicators
Each of the topics covered in this publication is presented over two pages. The first
provides a brief commentary highlighting the key findings conveyed by the data, defines
the indicator(s) and discusses any significant national variations from that definition
which might affect data comparability. On the facing page is a set of figures. These typically
show current levels of the indicator and, where possible, trends over time. In some cases,
an additional figure relating the indicator to another variable is included.
The average in the figures includes only European Union (EU) member states, and is
calculated as the unweighted average of those EU member states presented (up to 27, if there
is full data coverage). Some weighted averages are also presented in the tables on health
expenditure and GDP in the annex.
Data and limitations
Limitations in data comparability are indicated both in the text (in the box related to
“Definition and comparability”) as well as in footnotes to charts.
Readers interested in using the data presented in this publication for further analysis
and research are encouraged to consult the full documentation of definitions, sources and
methods contained in OECD Health Data 2012 for all OECD member countries, including
21 EU member states and 4 additional countries (Iceland, Norway, Switzerland and Turkey).
This information is available on OECD.Stat (http://stats.oecd.org/index.aspx?DataSetCode=
HEALTH_STAT).
For ten other countries (Bulgaria, Croatia, Cyprus, Former Yugoslav Republic of
Macedonia, Latvia, Lithuania, Malta, Montenegro, Romania and Serbia), readers should
consult the Eurostat database for more information on sources and methods: http://
epp.eurostat.ec.europa.eu/portal/page/portal/statistics/search_database.
Readers interested in an interactive presentation of the ECHI indicators can also consult
the DG SANCO HEIDI data tool at: http://ec.europa.eu/health/indicators/indicators/index_en.htm.
Population figures
The population figures for all EU member states and candidate countries presented in
the annex and used to calculate rates per capita in this publication come from the Eurostat
demographics database. The data were extracted in June 2012, and relate to mid-year
estimates (calculated as the average between the beginning and end of year population
figures). Population estimates are subject to revision, so they may differ from the latest
population figures released by Eurostat or national statistical offices.
Some member states such as France and the United Kingdom have overseas colonies,
protectorates and territories. These populations are generally excluded. However, the
calculation of GDP per capita and other economic measures may be based on a different
population in these countries, depending on the data coverage.
13
INTRODUCTION
Country codes (ISO codes)
Austria
AUT
Lithuania
LTU
Belgium
BEL
Luxembourg
LUX
Bulgaria
BGR
Malta
MLT
Croatia
HRV
Montenegro
MNE
Cyprus1
CYP
Netherlands
NLD
Czech Republic
CZE
Norway
NOR
Denmark
DNK
Poland
POL
Estonia
EST
Portugal
PRT
Finland
FIN
Romania
ROU
France
FRA
Serbia
SRB
FYR of Macedonia
MKD
Slovenia
SVN
Germany
DEU
Slovak Republic
SVK
Greece
GRC
Spain
ESP
Hungary
HUN
Sweden
SWE
Iceland
ISL
Switzerland
CHE
Ireland
IRL
Turkey
TUR
Italy
ITA
United Kingdom
GBR
Latvia
LVA
1. Note by Turkey: The information in this document with reference to “Cyprus” relates to the southern part of the
Island. There is no single authority representing both Turkish and Greek Cypriot people on the Island. Turkey
recognises the Turkish Republic of Northern Cyprus (TRNC). Until a lasting and equitable solution is found within
the context of United Nations, Turkey shall preserve its position concerning the “Cyprus” issue.
Note by all the European Union member states of the OECD and the European Commission: The Republic of Cyprus
is recognised by all members of the United Nations with the exception of Turkey. The information in this document
relates to the area under the effective control of the Government of the Republic of Cyprus.
14
© OECD 2012
Chapter 1
Health status
1.1.
Life expectancy and healthy life expectancy at birth . . . . . . . . . . . . .
16
1.2.
Life expectancy and healthy life expectancy at age 65 . . . . . . . . . . . .
18
1.3.
Mortality from all causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20
1.4.
Mortality from heart disease and stroke . . . . . . . . . . . . . . . . . . . . . . . .
22
1.5.
Mortality from cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24
1.6.
Mortality from transport accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26
1.7.
Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28
1.8.
Infant mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30
1.9.
Infant health: Low birth weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32
1.10. Self-reported health and disability. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34
1.11. Incidence of selected communicable diseases . . . . . . . . . . . . . . . . . . .
36
1.12. HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38
1.13. Cancer incidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40
1.14. Diabetes prevalence and incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42
1.15. Dementia prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44
1.16. Asthma and COPD prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
46
15
1.1. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT BIRTH
Life expectancy at birth continues to increase in
European countries, reflecting reductions in mortality rates
at all ages. These gains in longevity can be attributed to a
number of factors, including rising living standards,
improved lifestyle and better education, as well as greater
access to quality health services. Better nutrition, sanitation and housing also play a role, particularly in countries
with developing economies (OECD, 2011b).
Average life expectancy at birth for 2008-10 across the
27 member states of the European Union reached 75.3 years
for men and 81.7 years for women (Figure 1.1.1), a rise of 2.7
and 2.3 years respectively over the decade from 1998-2010. In
more than two-thirds of EU member states, life expectancy
exceeded 80 years for women and 75 years for men. France
had the highest life expectancy at birth for women in 2008-10
(85.0 years), and Sweden for men (79.4 years). Life expectancy
was lowest in Bulgaria and Romania for women (77.3 years)
and in Lithuania for men (67.3 years). The gap between
EU member states with the highest and lowest life expectancies is around eight years for women and 12 years for men.
The gender gap in life expectancy at birth in 2008-10
stood at 6.4 years, around half a year less than a decade
earlier. However, this hides a large range among countries,
with the smallest gap in Sweden, the Netherlands and the
United Kingdom, along with Iceland (about four years) and
the largest in Lithuania (over 11 years). The recent narrowing of this gap in most countries can be attributed at least
partly to the narrowing of differences in risk-increasing
behaviours between men and women, such as smoking,
accompanied by sharp reductions in mortality rates from
cardiovascular diseases among men.
Looking ahead, Eurostat projects that life expectancy
will continue to increase in the European Union in coming
decades, to reach 84.6 years for males and 89.1 for females
in 2060. Convergence among countries is expected to
continue, with the largest increases in life expectancy to
take place in those countries with the lowest life expectancy in 2010 (EC, 2012a).
In a context of increasing life expectancy and population ageing, healthy life years (HLY) has been endorsed as an
important European policy indicator to address whether
years of longer life are lived in good health (Joint Action:
EHLEIS, 2012). The current leading indicator of HLY is a
measure of disability-free life expectancy which indicates
how long people can expect to live without disability. On
average for EU member states, HLY at birth in 2008-10 was
62.2 years for women and 61.0 years for men. It was greatest
in Malta for women, and in Sweden for men, and shortest in
the Slovak Republic for both men and women (Figure 1.1.1).
Women in Malta can expect to live 86% of life expectancy
without limitations in usual activities. For men in Sweden,
the value is even higher at 89%. In the Slovak Republic, only
66% of female and 73% of male life expectancy is free from
activity limitation.
The spread of values for HLY at birth among
EU member states are much greater than for life expectancy, being 19 years for women and 18 years for men.
16
Since the HLY indicator has only recently been developed,
there is as yet no long time series. In contrast to the 6.4 year
gap in life expectancy at birth for EU member states on
average, the gender gap in HLY at birth was only around
1.2 years in 2008-10. For life expectancy at birth the gender
gap has always favoured women. However, seven countries
had a gender gap in HLY which favoured men, the greatest
being 2.0 more HLY for men in Portugal. Of the remaining
countries, Lithuania had the largest gender gap in HLY
favouring women. The European Innovation Partnership on
Active and Healthy Ageing, part of the Europe 2020 initiative, has set an objective of increasing the average number
of healthy life years by two, by 2020 (EC, 2011b).
A wide range of factors affect life expectancy and HLY.
Higher national income (as measured by GDP per capita) is
generally associated with higher life expectancy at birth
and also with HLY, although the relationship is less pronounced at higher levels of national income (Figure 1.1.2).
Similarly, Figure 1.1.3 shows that higher health spending
per capita tends to be associated with higher HLY, although
there is much variation for a given level of health spending,
confirming that many other factors play a role in determining the number of healthy life years.
Definition and comparability
Life expectancy measures how long, on average,
people would live based on a given set of age-specific
death rates. However, the actual age-specific death
rates of any particular birth cohort cannot be known
in advance. If age-specific death rates are falling (as
has been the case over the past decades), actual life
spans will, on average, be higher than life expectancy
calculated with current death rates.
Healthy life years (HLY) are the number of years
spent free of activity limitation, being equivalent to
disability-free life expectancy. HLY are calculated
annually by Eurostat and EHLEIS for each EU country
using the Sullivan (1971) method. The underlying
health measure is the Global Activity Limitation
Indicator (GALI), which measures limitation in usual
activities, and comes from the European Union Statistics on Income and Living Conditions (EU-SILC) survey.
Comparing trends in HLY and life expectancy can
show whether extra years of life are healthy years.
However, valid comparisons depend on the underlying
health measure being truly comparable. While HLY is
the most comparable indicator to date, there are still
problems with translation of the GALI question,
although it does appear to satisfactorily reflect other
health and disability measures (Jagger et al., 2010).
1.1. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT BIRTH
1.1.1. Life expectancy (LE) and healthy life years (HLY) at birth, by gender, 2008-10 average
HLY
LE with activity limitation
Life expectancy
Females
Males
France
Spain
Italy
Sweden
Finland
Cyprus
Austria
Luxembourg
Malta
Germany
Netherlands
Slovenia
Belgium
Ireland
Greece
Portugal
United Kingdom
EU27
Denmark
Czech Republic
Poland
Estonia
Slovak Republic
Hungary
Lithuania
Latvia
Romania
Bulgaria
85.0
84.9
84.6
83.5
83.4
83.4
83.3
83.3
82.9
82.8
82.8
82.8
82.8
82.7
82.6
82.6
82.3
81.7
81.2
80.6
80.3
80.2
79.1
78.4
78.4
78.1
77.3
77.3
78.7
79.3
79.4
76.7
78.6
77.8
78.0
78.1
77.8
78.7
75.9
77.3
78.0
78.0
76.5
78.2
75.3
76.9
74.3
71.6
69.7
71.3
70.3
67.3
67.9
69.8
70.1
Switzerland
Iceland
Norway
Croatia
Turkey
Montenegro
FYR of Macedonia
Serbia
84.7
83.7
83.2
79.9
78.8
78.0
76.8
76.8
90
Years
78.0
80
70
60
50
40
30
80.0
79.9
78.7
73.5
73.3
73.1
72.5
71.5
30
40
50
60
70
80
90
Years
Source: Eurostat Statistics Database; Joint Action: EHLEIS (2012).
1 2 http://dx.doi.org/10.1787/888932702879
1.1.2. Healthy life years (HLY) at birth
and GDP per capita, 2008-10 average
1.1.3. Healthy life years (HLY) at birth
and health spending per capita, 2008-10 average
HLY (years)
75
HLY (years)
75
R 2 = 0.21
MLT
70
SWE
BGR
65
CZE
POL
CYP
ESP
GBR IRL
70
NOR
ISL
GRC
BEL
LUX
55
SWE
NOR
ISL
GRC
GBR
CYP
65
BGR
CHE
ROU
DNK
ITA
ROU
NLD
FRA
AUT
HRV
FIN
SVN
LTU
PRT
DEU
HUN
EST
LVA
60
R 2 = 0.15
MLT
POL
60
HUN
EST
ITA
LUX
IRL
BEL
CHE
FRA DNK
NLD
HRV
LTU
55
CZE
ESP
AUT
SVN
FIN
PRT
DEU
LVA
SVK
SVK
50
50
0
20 000
40 000
60 000
GDP per capita (EUR PPP)
Source: Eurostat Statistics Database; OECD Health Data 2012; WHO Global
Health Expenditure Database.
1 2 http://dx.doi.org/10.1787/888932702898
0
1 000
2 000
3 000
4 000
5 000
Health spending per capita (EUR PPP)
Source: Eurostat Statistics Database; OECD Health Data 2012; WHO Global
1 2 http://dx.doi.org/10.1787/888932702917
17
1.2. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT AGE 65
Life expectancy at age 65 has increased significantly
among both women and men over the past several decades
in all EU member states. Some of the factors explaining the
gains in life expectancy at age 65 include advances in
medical care, greater access to health care, healthier lifestyles and improved living conditions before and after
people reach age 65.
The average life expectancy at age 65 in 2008-10 for the
27 member states of the European Union was 16.5 years for
men and 20.1 years for women (Figure 1.2.1). As for life expectancy at birth, France had the highest life expectancy at age 65
for women (23.2 years), but also for men (18.7 years). Among
other countries, life expectancy at 65 was highest in
Switzerland for both men and women. Life expectancy at
age 65 in the European Union was lowest in Latvia for men
(13.2 years) and in Bulgaria for women (16.9 years).
The average gender gap in life expectancy at age 65
in 2008-10 stood at 3.6 years, unchanged since 1998-2000.
Greece had the smallest gender gap of 2 years and Estonia
the largest at 5.2 years.
Gains in longevity at older ages in recent decades,
combined with the trend reduction in fertility rates are
contributing to a steady rise in the proportion of older
persons (see Annex Table A.2). Whether longer life expectancy is accompanied by good health and functional status
among ageing populations has important implications for
health and long-term care systems.
Healthy life years (HLY) at age 65 in 2008-10 for
EU member states was similar for men and women, being
8.4 years for men and 8.6 years for women. HLY at age 65
in 2008-10 was greatest in Sweden and shortest in the
Slovak Republic for both men and women (Figure 1.2.1).
HLY is based on the Global Activity Limitation (GALI)
question, which is one of three indicators included in the
Minimum European Health Module along with global items
on self-perceived health and chronic morbidity. Since the
HLY indicator has only been developed relatively recently,
there is as yet no long time series.
The relationship between life expectancy and HLY at
age 65 is not clear-cut (Figure 1.2.2). Higher life expectancy
at age 65 is generally associated with higher HLY, although
longer life expectancy at age 65 does not necessarily imply
more HLY. Central and Eastern European countries have
both lower life expectancy and HLY than other European
countries.
Life expectancy at age 65 years also varies by educational status (Figure 1.2.3). For both men and women, highly
educated people are likely to live longer (Corsini, 2010).
Again, differences in life expectancy are particularly large in
Central and Eastern European countries, and are more
pronounced for men. In the Czech Republic, 65-year-old men
with a high level of education can expect to live seven years
longer than those with a low education level. Not only is
18
education a general measure of socio-economic status, it
can also provide the means to improve the social and
economic conditions in which people live and work.
A recent study showed that higher educational levels
are not only associated with higher life expectancy but also
with higher disability-free life expectancy at age 65 in ten
EU member states. For both men and women, differences
were larger for disability-free life expectancy than life
expectancy (Majer et al., 2011).
In several European countries, occupation is used as a
measure of socio-economic status. In the United Kingdom
for the period 2002-06, 65-year-old men classified as “Higher
managerial and professional” could expect to live 3.5 years
longer than men in “Routine occupations”, and this gap
had widened over the previous two decades. The gap
for women was similar at 3.2 years. In France, in 2003,
65-year-old men who had highly qualified occupations could
expect to live 3.1 years longer in total and 3.7 years longer
without disability than men who were manual workers.
These gaps were respectively 1.7 years and 3.2 years for
women (Cambois et al., 2011).
Life expectancy measures how long, on average,
people would live based on a given set of age-specific
death rates. However, the actual age-specific death
rates of any particular birth cohort cannot be known
in advance. If age-specific death rates are falling (as
has been the case over the past decades), actual life
spans will, on average, be higher than life expectancy
calculated with current death rates.
Healthy life years (HLY) are the number of years
spent free of activity limitation, being equivalent to
disability-free life expectancy. HLY are calculated
annually by Eurostat and EHLEIS for each EU country
using the Sullivan (1971) method. The underlying
health measure is the Global Activity Limitation Indicator (GALI), which measures limitation in usual
activities, and comes from the European Union
Statistics on Income and Living Conditions (EU-SILC)
survey.
Comparing trends in HLY and life expectancy can
show whether extra years of life are healthy years.
However, valid comparisons depend on the underlying
health measure being truly comparable. While HLY is
the most comparable indicator to date, there are still
problems with translation of the GALI question,
although it does appear to satisfactorily reflect other
health and disability measures (Jagger et al., 2010).
1.2. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT AGE 65
1.2.1. Life expectancy (LE) and healthy life years (HLY) at 65, by gender, 2008-10 average
HLY
LE with activity limitation
Life expectancy
Females
Males
France
Spain
Italy
Finland
Luxembourg
Austria
Belgium
Sweden
Netherlands
Germany
United Kingdom
Ireland
Slovenia
Cyprus
Malta
Portugal
Greece
EU27
Denmark
Poland
Estonia
Czech Republic
Lithuania
Hungary
Latvia
Slovak Republic
Romania
Bulgaria
23.2
22.4
22.1
21.4
21.3
21.2
21.1
21.1
20.9
20.8
20.7
20.7
20.7
20.7
20.6
20.5
20.1
20.1
19.6
19.3
19.2
18.9
18.3
18.2
18.1
17.9
17.2
16.9
21.1
21.0
18.4
18.2
17.0
16.1
15.8
20
18.3
17.4
17.4
17.8
17.5
18.2
17.6
17.6
18.0
17.4
16.5
18.0
17.4
17.0
18.1
16.5
16.8
14.9
13.9
15.3
13.4
14.0
13.2
14.0
14.0
13.6
Switzerland
Norway
Iceland
Turkey
Croatia
Montenegro
Serbia
FYR of Macedonia
22.3
25
Years
18.7
18.3
15
10
5
0
19.0
17.9
18.4
15.2
14.6
14.8
13.9
13.8
0
5
10
15
20
25
Years
Source: Eurostat Statistics Database; Joint Action: EHLEIS (2012).
1 2 http://dx.doi.org/10.1787/888932702936
1.2.2. Relationship between life expectancy
and healthy life years (HLY) at 65,
2008-10 average
1.2.3. Life expectancy gaps between high
and low education attainment at 65, women and men,
2010 (or nearest year)
Men
Healthy life years (HLY)
16
R 2 = 0.37
NOR
14
SWE
ISL
DNK
12
10
LUX
BEL
IRL
BGR
8
POL
LTU
4
NLD
CYP
SVN
ROU
6
EU
CZE
GRC
FIN
AUT
ESP
FRA
ITA
DEU
HRV
HUN
EST
LVA
CHE
GBR
MLT
PRT
SVK
0
16
Bulgaria
Czech Republic
Denmark
Estonia
Finland
Hungary
Italy
Malta
Poland
Portugal
Romania
Slovenia
Sweden
Croatia
FYR of Macedonia
Norway
2
14
Women
18
20
22
Life expectancy (years)
Source: Eurostat Statistics Database.
1 2 http://dx.doi.org/10.1787/888932702955
0
2
4
6
8
Years
1 2 http://dx.doi.org/10.1787/888932702974
19
1.3. MORTALITY FROM ALL CAUSES
Statistics on deaths remain one of the most widely
available and comparable sources of information on health.
Registering deaths is compulsory in all European countries,
and the data collected through the process of registration
can be used by statistical and health authorities to monitor
diseases and health status, and to plan health services. In
order to compare levels of mortality across countries and
over time, the data need to be standardised to remove the
effect of differences in age structure.
In 2010 there were large variations in age-standardised
mortality rates for all causes of death across European
countries. Death rates were lowest in Spain and Italy, at
less than 500 deaths per 100 000 population (Figure 1.3.1).
The rate in Switzerland was also low. Rates in northern,
western and southern European countries were lower than
the EU average rate of 663. They were highest in Baltic and
central European countries – Bulgaria, Latvia, Lithuania
and Romania, for instance, had age-standardised rates
almost twice those of the lowest countries at over
900 deaths per 100 000 population. Rates in Estonia,
Hungary and the Slovak Republic were above 800.
Male mortality rates were lowest in Malta, Sweden and
Italy, and among other countries, in Iceland and Switzerland.
They were high in Latvia and Lithuania. Female rates were
low in France, Italy and Spain, as well as in Switzerland, and
high in Bulgaria and Romania, along with the Former
Yugoslav Republic of Macedonia. A significant gender gap
exists in mortality rates (Figure 1.3.1). Across all EU member
states, the male mortality rate was, on average, 70% higher
than the female rate in 2010. But large differences exist
among countries – in Estonia, Latvia and Lithuania, male
rates were more than twice those of females, whereas in the
Denmark, the Netherlands, Sweden and the United Kingdom,
they were only around 40% higher.
Lower mortality rates translate into higher life expectancies (see Indicator 1.1 “Life expectancy and healthy life
expectancy at birth”). Differences in life expectancy among
countries with the lowest and highest mortality rates are in
the order of 8 years for females and 12 years for males.
Some important causes of mortality that have been
influenced through effective public health measures
include ischemic heart disease, lung cancer, alcohol-
20
related mortality, suicide, transport accidents, cervical
cancer and AIDS (Cayotte and Buchow, 2009).
Although mortality rates in central Europe are still
comparatively high, significant declines have occurred in
a number of these countries since 1995 (Figures 1.3.2
and 1.3.3). Mortality rates in the Czech Republic, Estonia,
Hungary, Poland and Slovenia have fallen by more than
25%, a decline that is greater than the EU average. Ireland
has also seen a decline of close to 40%, driven largely by
reductions in cardiovascular and respiratory diseases mortality, which in turn may be linked to rising living standards
and increased expenditure on public and private health
services in recent decades. In contrast, declines in the
Slovak Republic, Bulgaria and Lithuania have been smaller.
Declines in Belgium, Greece and Sweden have also been
modest, although these countries began the period with
rates that were already low.
The leading causes of death in Europe include cardiovascular diseases (such as heart attack and stroke), and
cancer. Deaths from these diseases, plus selected external
causes of death (transport accidents and suicide), are
examined more closely in the following four indicators.
Mortality rates are based on numbers of deaths
registered in a country in a year divided by the size of
the corresponding population. The rates have been
directly age-standardised to the WHO European
standard population to remove variations arising
from differences in age structures across countries
and over time. The source is the Eurostat Statistics
Database.
Deaths from all causes are classified to ICD-10
Codes A00-Y89, excluding S00-T98. Mathers et al.
(2005) have provided a general assessment of the
coverage, completeness and reliability of data on
causes of death.
1.3. MORTALITY FROM ALL CAUSES
1.3.1. Mortality rates from all causes of death, 2010 (or nearest year)
Males
Total population
Females
Males and females
Spain
Italy
France
Malta
Sweden
Luxembourg
Cyprus
Netherlands
Ireland
United Kingdom
Austria
Germany
Finland
Greece
Slovenia
Belgium
Portugal
Denmark
EU27
Czech Republic
Poland
Estonia
Slovak Republic
Hungary
Latvia
Romania
Lithuania
Bulgaria
488
496
510
517
520
525
532
543
545
554
563
565
574
577
601
601
602
644
663
724
776
840
855
898
951
959
964
970
391
376
537
794
965
1 200
900
600
Age-standardised rates per 100 000 population
300
0
626
430
628
679
434
416
656
424
659
660
454
450
655
468
718
697
442
453
755
429
693
474
801
449
765
474
783
772
460
541
866
509
940
557
1 065
557
1 246
577
1 151
1 208
640
673
1 362
682
1 237
733
1 418
660
1 251
747
Switzerland
Iceland
Norway
Croatia
FYR of Macedonia
490
507
642
632
679
362
394
422
441
614
604
657
1 029
616
1 127
823
0
500
1 000
1 500
Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population.
1 2 http://dx.doi.org/10.1787/888932702993
1.3.2. Decline in mortality rates from all causes,
1995-2010 (or nearest year)
Ireland
Estonia
Slovenia
Portugal
Malta
Czech Republic
Luxembourg
United Kingdom
Spain
Poland
Germany
Italy
Denmark
Hungary
Finland
Netherlands
EU25
Austria
France
Latvia
Greece
Sweden
Belgium
Lithuania
Bulgaria
Slovak Republic
1.3.3. Trends in mortality rates from all causes,
selected EU member states, 1995-2010
37
Bulgaria
35
Ireland
Spain
EU25
1 400
33
31
30
29
28
27
27
27
26
26
26
26
26
25
25
24
23
23
1 200
1 000
800
20
20
19
19
17
16
Iceland
Norway
Switzerland
600
29
24
23
0
10
20
30
40
50
Percentage decline
Source: Eurostat Statistics Database. Data are age-standardised to the
WHO European standard population.
1 2 http://dx.doi.org/10.1787/888932703012
400
1995
2000
2005
2010
1 2 http://dx.doi.org/10.1787/888932703031
21
1.4. MORTALITY FROM HEART DISEASE AND STROKE
Cardiovascular diseases are the main cause of mortality in almost all EU member states, accounting for 36% of
all deaths in the region in 2010. They cover a range of
diseases related to the circulatory system, including
ischemic heart disease (known as IHD, or heart attack) and
cerebro-vascular disease (or stroke). Together, IHD and
stroke comprise 60% of all cardiovascular deaths, and
caused more than one-fifth of all deaths in EU member
states in 2010.
Ischemic heart disease is caused by the accumulation
of fatty deposits lining the inner wall of a coronary artery,
restricting blood flow to the heart. IHD alone was responsible for 13% of all deaths in EU member states in 2010. Mortality from IHD varies considerably, however (Figure 1.4.1);
Baltic countries report the highest IHD mortality rates,
Lithuania for both males and females, followed by Latvia,
the Slovak Republic and Estonia. IHD mortality rates are also
relatively high in Finland and Malta, with rates several times
higher than in France, Portugal, the Netherlands and Spain.
There are regional patterns to the variability in IHD mortality rates. Besides the Netherlands and Luxembourg, the
countries with the lowest IHD mortality rates are four
countries located in Southern Europe: France, Italy, Portugal
and Spain, with Cyprus and Greece also having low rates.
This lends support to the commonly held hypothesis that
there are underlying risk factors, such as diet, which explain
differences in IHD mortality across countries.
Death rates for IHD are much higher for men than for
women in all countries (Figure 1.4.1). On average across
EU member states, IHD mortality rates in 2010 were nearly
two times greater for men. The disparity was greatest in
Cyprus, France and Luxembourg, with male rates two-tothree times higher, and least in Malta, Romania and the
Slovak Republic, at 60% higher.
Since the mid-1990s, IHD mortality rates have
declined in nearly all countries (Figure 1.4.3). The decline
has been most remarkable in Denmark, Ireland, the
Netherlands and the United Kingdom. Estonia and Norway
also saw IHD mortality rates cut by one-half or more,
although rates in Estonia are still high. Declining tobacco
consumption contributed significantly to reducing the incidence of IHD, and consequently to reducing mortality rates.
Improvements in medical care have also played a part [see
Indicator 3.8 “Cardiac procedures (coronary angioplasty)”].
A small number of countries, however, have seen little or
22
no decline since 1995. Declines in Hungary, Poland and the
Slovak Republic have been moderate, at under 20%.
Stroke was the underlying cause for about 9% of all
deaths in 2010. It is a loss of brain function caused by the disruption of the blood supply to the brain. In addition to being
an important cause of mortality, the disability burden from
stroke is substantial (Moon et al., 2003). As with IHD, there are
large variations in stroke mortality rates across countries
(Figure 1.4.2). Again, the rates are highest in Baltic and central
European countries, including Bulgaria, Hungary, Latvia,
Lithuania, Romania and the Slovak Republic. They are the
lowest in Cyprus, France, Ireland and the Netherlands. Rates
are also low in Switzerland, Iceland and Norway.
Looking at trends over time, stroke mortality has
decreased in all EU member states since 1995, with a more
pronounced fall after 2003 (Figure 1.4.4). Rates have
declined by around 60% in Austria, Estonia and Portugal.
The decline has only been moderate in Lithuania, Poland
and the Slovak Republic. As with IHD, the reduction in
stroke mortality can be attributed at least partly to a reduction in risk factors. Tobacco smoking and hypertension are
the main modifiable risk factors for stroke. Improvements
in medical treatment for stroke have also increased
survival rates (see Indicator 4.4 “In-hospital mortality
following stroke”).
Database.
Deaths from ischemic heart disease are classified to
ICD-10 Codes I20-I25, and stroke to I60-I69. Mathers
et al. (2005) have provided a general assessment of the
coverage, completeness and reliability of data on
causes of death.
1.4. MORTALITY FROM HEART DISEASE AND STROKE
1.4.1. Ischemic heart disease, mortality rates,
Males
France
Portugal
Netherlands
Spain
Luxembourg
Italy
Denmark
Belgium
Slovenia
Greece
Cyprus
Germany
United Kingdom
Sweden
Ireland
Austria
Malta
Poland
Bulgaria
EU27
Finland
Czech Republic
Romania
Hungary
Estonia
Slovak Republic
Latvia
Lithuania
Females
Males
50
19
29
56
27
59
27
65
27
69
40
80
41
84
38
88
41
95
41
97
109
37
57
111
50
111
117
58
128
61
131
73
132
85
133
60
81
156
81
156
177
79
213
123
240
147
282
167
299
150
338
211
378
178
429
230
Norway
Switzerland
Iceland
FYR of Macedonia
Croatia
1.4.2. Stroke, mortality rates,
45
92
45
93
55
118
63
119
0
100
200
300
400
500
Females
31
23
34
31
36
37
38
37
30
38
30
38
38
33
41
43
41
43
37
44
37
45
37
47
39
47
38
49
51
41
71
49
74
75
75
58
80
67
82
58
83
65
84
55
109
77
110
73
139
106
161
114
195
150
214
152
Switzerland
Iceland
Norway
Croatia
FYR of Macedonia
208
131
France
Netherlands
Cyprus
Ireland
Austria
Spain
Germany
Malta
United Kingdom
Belgium
Sweden
Denmark
Luxembourg
Finland
Italy
Slovenia
Greece
EU27
Czech Republic
Poland
Portugal
Estonia
Slovak Republic
Hungary
Lithuania
Latvia
Romania
Bulgaria
27
31
32
43
33
43
125
94
198
174
0
50
100
150
200
250
1 2 http://dx.doi.org/10.1787/888932703050
1 2 http://dx.doi.org/10.1787/888932703069
1.4.3. Trends in ischemic heart disease mortality rates,
1.4.4. Trends in stroke mortality rates,
Denmark
France
Lithuania
Bulgaria
EU
500
400
200
300
150
200
100
100
50
0
1995
1997
1999
2001
Estonia
France
EU
250
2003
2005
2007
2009
1 2 http://dx.doi.org/10.1787/888932703088
0
1995
1997
1999
2001
2003
2005
2007
2009
1 2 http://dx.doi.org/10.1787/888932703107
23
1.5. MORTALITY FROM CANCER
Cancer is the second leading cause of mortality in
EU member states after diseases of the circulatory system,
accounting for 28% of all deaths in 2010. In 2010, cancer
mortality rates were the lowest in Cyprus, Finland and
Sweden, as well as Switzerland, at under 150 deaths per
100 000 population. They were the highest in central
European countries, including the Czech Republic,
Hungary, Poland, the Slovak Republic and Slovenia, at close
to or above 200 deaths per 100 000 population.
Cancer mortality rates are higher for men than for
women (Figure 1.5.1). In 2010, the gender gap was particularly wide in Estonia, Latvia, Lithuania, Portugal, the
Slovak Republic and Spain, with mortality rates among
men more than twice those for women. This gap can be
explained partly by the greater prevalence of risk factors
among men, as well as the lesser availability or use of
screening programmes for cancers affecting men, leading
to lower survival rates after diagnosis.
Lung cancer still accounts for the greatest number of
cancer deaths among men in EU member states, except in
Sweden. Lung cancer is also one of the main causes of
cancer mortality among women. Smoking is the most
important risk factor for lung cancer. In 2010, death
rates from lung cancer among men were the highest in
Baltic and central European countries (Hungary, Latvia,
Lithuania, Poland, as well as Croatia) (Figure 1.5.2). These
are all countries where smoking rates among men are
relatively high. Death rates from lung cancer among men
are low in Nordic countries (Finland, Iceland, Norway and
Sweden) as well as in Cyprus, countries with low smoking
rates among men (see Indicator 2.5 “Smoking among
adults”). Denmark and Iceland, however, have high rates of
lung cancer mortality among women.
Breast cancer is the most common form of cancer
among women in all European countries (Ferlay et al., 2010).
It accounted for around 30% of cancer incidence among
women in 2008, and 18% of female cancer deaths in 2010.
While there has been an increase in incidence rates of
breast cancer over the past decade, death rates have
declined or remained stable, indicating increases in
survival rates due to earlier diagnosis and better treatment
(see Indicator 4.8 “Screening, survival and mortality for
breast cancer”). The lowest mortality rates from breast
cancer are in Bulgaria, Portugal, Spain and Sweden, as well
as Norway (below 20 deaths per 100 000 females), while the
highest rates are in Belgium and Denmark (close to 30)
(Figure 1.5.3).
Prostate cancer has become the most commonly
occurring cancer among men in many European countries,
24
particularly for those aged over 65 years of age, although
death rates from prostate cancer remain lower than for lung
cancer in all countries except Sweden. The rise in the
reported incidence of prostate cancer in many countries
during the 1990s and 2000s was largely due to the greater use
of prostate-specific antigen (PSA) diagnostic tests. Death rates
from prostate cancer in 2010 varied from lows of less than 15
per 100 000 males in Malta and Luxembourg – although
annual numbers of deaths are small in these countries – to
highs of more than 30 per 100 000 males in a range of central
European and Nordic countries (Figure 1.5.4). The causes of
prostate cancer are not well understood. Some evidence
suggests that environmental and dietary factors might
influence the risk of prostate cancer (Institute of Cancer
Research, 2012).
Death rates from all types of cancer for males and
females have declined at least slightly in most member
states since 1995, although the decline has been more
modest than for cardiovascular diseases, explaining why
cancer now accounts for a larger share of all deaths. The
exceptions to this declining pattern are among Baltic and
central European countries – Bulgaria, Latvia, Lithuania,
Romania and the Former Yugoslav Republic of Macedonia –
where cancer mortality has remained static or increased.
Database.
Deaths from all cancers are classified to ICD-10
Codes C00-C97, lung cancer to C32-C34, breast cancer
to C50 and prostate cancer to C61. The international
comparability of cancer mortality data can be affected
by differences in medical training and practices as
well as in death certification procedures across countries. Mathers et al. (2005) have provided a general
assessment of the coverage, completeness and
reliability of data on causes of death.
1.5. MORTALITY FROM CANCER
1.5.1. All cancers mortality rates, males and females,
Males
Cyprus
Sweden
Finland
Malta
Germany
Ireland
United Kingdom
Austria
Greece
Luxembourg
Bulgaria
Italy
Spain
Denmark
Portugal
Netherlands
Belgium
France
EU27
Romania
Czech Republic
Slovenia
Poland
Slovak Republic
Estonia
Latvia
Lithuania
Hungary
99
130
114
128
128
148
147
126
109
120
114
122
102
168
108
152
129
116
132
130
148
146
147
139
136
143
133
Females
248
263
270
271
284
286
288
293
333
186
187
191
134
117
133
228
128
298
153
0
Males
153
168
174
184
199
200
202
204
207
212
212
212
218
219
220
227
227
229
230
175
Iceland
Switzerland
Norway
FYR of Macedonia
Croatia
100
1.5.2. Lung cancer mortality rates, males and females,
Sweden
Cyprus
Finland
Ireland
Austria
United Kingdom
Portugal
Malta
Germany
Luxembourg
Denmark
Italy
France
EU27
Netherlands
Spain
Bulgaria
Czech Republic
Slovak Republic
Slovenia
Greece
Estonia
Romania
Belgium
Lithuania
Latvia
Poland
Hungary
28
19
32
9
13
20
17
43
42
45
48
50
50
50
51
52
55
56
61
62
64
65
67
68
70
70
71
73
15
16
19
32
11
10
20
15
20
13
12
13
20
9
10
76
78
80
82
83
92
24
116
40
Iceland
Norway
Switzerland
FYR of Macedonia
Croatia
200
300
400
Females
29
23
10
15
39
37
44
45
25
19
13
76
88
19
0
25
50
75
100
125
1 2 http://dx.doi.org/10.1787/888932703126
1 2 http://dx.doi.org/10.1787/888932703145
1.5.3. Breast cancer mortality rates, females,
1.5.4. Prostate cancer mortality rates, males,
Spain
Sweden
Bulgaria
Poland
Portugal
Czech Republic
Greece
Finland
Cyprus
Slovak Republic
Estonia
Romania
Austria
Italy
EU27
France
Germany
Lithuania
United Kingdom
Slovenia
Hungary
Latvia
Luxembourg
Malta
Ireland
Netherlands
Belgium
Denmark
17.7
19.1
19.4
19.8
20.0
20.6
21.1
21.2
21.5
22.0
22.1
22.6
22.8
23.0
23.2
23.6
24.0
24.2
24.5
24.8
25.0
25.2
25.5
25.8
26.2
26.8
28.3
28.9
Norway
Iceland
Switzerland
FYR of Macedonia
Croatia
19.0
20.1
22.1
23.7
27.6
0
10
20
30
40
Age-standardised rates per 100 000 females
1 2 http://dx.doi.org/10.1787/888932703164
Malta
Luxembourg
Italy
Romania
Bulgaria
Greece
Spain
Cyprus
Germany
France
Austria
Belgium
Poland
Hungary
EU27
Czech Republic
Finland
Slovak Republic
Portugal
United Kingdom
Netherlands
Ireland
Slovenia
Lithuania
Denmark
Sweden
Latvia
Estonia
12.0
14.6
15.1
15.4
15.5
16.6
17.3
17.5
20.0
20.1
20.6
20.9
20.9
21.6
22.6
23.1
23.2
23.2
23.4
23.8
25.1
25.2
31.0
31.3
32.1
32.3
32.4
36.6
FYR of Macedonia
Switzerland
Croatia
Iceland
Norway
17.4
24.5
28.1
29.8
32.6
0
10
20
30
40
Age-standardised rates per 100 000 males
1 2 http://dx.doi.org/10.1787/888932703183
25
1.6. MORTALITY FROM TRANSPORT ACCIDENTS
Injuries from transport accidents – most of which are
due to road traffic – are a major public health problem in the
European Union, causing the premature deaths of some
40 000 people every year. In addition to these deaths, more
than 1.5 million people are estimated to be so seriously
injured as to require hospital admission each year (OECD/ITF,
2011a). Around 4 000-5 000 transport accident deaths
occurred in each of France, Germany, Italy and Poland in 2010.
Mortality from road accidents is the leading cause of
death among children and young people, and especially
young men, in many countries. Most fatal traffic injuries
occur in passenger vehicles, although the fatality risk for
motor cycles and scooters is highest among all modes of
transport.
The direct and indirect financial costs of transport
accidents are substantial; one estimate put these at up to
3% of gross national product annually in highly-motorised
countries (WHO, 2009a).
Death rates were the highest in Romania, Greece
and Lithuania in 2010, all in excess of 12 deaths per
100 000 population (Figure 1.6.1). They were the lowest in
Malta, the Netherlands, Sweden and the United Kingdom,
at less than four deaths per 100 000 population, much
lower than the EU average of 7.7. A four-fold difference
exists between the countries with the lowest and highest
rates.
In all EU member states, death rates from transport
accidents are much higher for males than for females, with
disparities ranging from three times higher in Denmark,
Germany, Ireland, Luxembourg, and the Netherlands, to
around five times higher in Cyprus and Greece. On average,
around four times as many males than females die in
transport accidents (Figure 1.6.1).
Much transport accident injury and mortality is
preventable. Road security has increased greatly over the
past decades in many countries through improvements of
road systems, education and prevention campaigns, the
adoption of new laws and regulations and the enforcement
of these laws through more traffic controls. As a result,
death rates due to transport accidents have been more
26
than halved across the European Union since 1995
(Figures 1.6.2 and 1.6.3). Estonia and Luxembourg have
seen the largest declines at 71% since 1995, with most of
the fall in Estonia occurring in the mid-1990s. Reductions in
Ireland, Portugal and Slovenia and a number of other
countries are more than 60% since 1995, although vehicle
kilometers travelled have increased substantially in the
same period (OECD/ITF, 2011a). Death rates have also
declined in Belgium, Greece and Bulgaria, but at a slower
pace, and therefore remain well above the EU average.
The effects of the economic crisis may have a favourable outcome on transport accident mortality. Many
countries had a slight decrease or stagnation in traffic
volumes since 2008, accompanied by a much more significant reduction in fatalities. However, in the long-term,
effective road safety policies are the main contributor to
reduced mortality (OECD/ITF, 2011b).
Database.
Deaths from transport accidents are classified to
ICD-10 Codes V01-V99. The majority of deaths from
transport accidents are due to road traffic accidents.
Mortality rates from transport accidents in Luxembourg
are biased upward because of the large volume of traffic
in transit, resulting in a significant proportion of nonresidents killed. Mathers et al. (2005) have provided a
general assessment of the coverage, completeness and
reliability of data on causes of death.
1.6. MORTALITY FROM TRANSPORT ACCIDENTS
1.6.1. Transport accident mortality rates, 2010 (or nearest year)
Males
Total population
Females
Males and females
United Kingdom
Malta
Sweden
Netherlands
Ireland
Germany
Luxembourg
Spain
Denmark
Finland
Austria
France
Slovenia
Italy
EU27
Czech Republic
Estonia
Portugal
Hungary
Slovak Republic
Bulgaria
Belgium
Cyprus
Latvia
Poland
Lithuania
Greece
Romania
3.4
3.6
3.8
3.9
4.2
4.4
4.8
5.1
5.5
5.9
6.9
6.9
7.1
7.4
7.7
8.1
8.1
8.3
8.9
8.9
9.1
10.0
10.5
10.8
11.0
12.8
13.6
15.1
7.2
10.3
20
15
10
5
0
5.1
2.4
5.0
5.9
5.8
1.6
2.1
6.4
2.2
6.7
7.3
2.3
2.5
8.2
2.1
8.0
3.0
2.5
9.5
2.8
11.2
3.0
2.8
11.1
11.8
2.9
12.2
3.4
3.3
12.3
12.9
13.2
3.9
3.6
3.9
13.4
14.4
3.8
14.4
14.5
15.5
3.8
4.6
3.3
18.0
16.8
17.9
5.5
4.5
5.0
21.7
22.3
4.8
24.0
6.9
Iceland
Switzerland
Norway
FYR of Macedonia
Croatia
4.2
5.0
5.2
1.6
7.6
8.3
0.7
1.9
8.4
2.0
10.8
3.7
4.1
0
16.9
5
10
15
20
25
30
1 2 http://dx.doi.org/10.1787/888932703202
1.6.2. Trends in transport accident mortality rates,
Greece
Slovenia
United Kingdom
EU25
Estonia
Luxembourg
Slovenia
Portugal
Ireland
Spain
Germany
Latvia
Hungary
Denmark
Netherlands
Austria
EU25
France
Lithuania
Poland
Czech Republic
Finland
United Kingdom
Italy
Malta
Slovak Republic
Sweden
Bulgaria
Greece
Belgium
25
20
15
10
5
0
1995
1.6.3. Decline in transport accident mortality rates,
71
71
66
66
65
64
62
61
52
51
51
51
51
50
48
48
47
45
44
44
44
43
41
39
37
36
Iceland
Switzerland
Norway
1997
1999
2001
2003
2005
2007
2009
1 2 http://dx.doi.org/10.1787/888932703221
71
50
38
0
20
40
60
80
100
Percentage decline
1 2 http://dx.doi.org/10.1787/888932703240
27
1.7. SUICIDE
The intentional killing of oneself can be seen as
evidence not only of personal breakdown, but also of a
deterioration of the social context in which an individual
lives. Suicide may be the end-point of a number of different
contributing factors. It is more likely to occur during crisis
periods associated with upheavals in personal relationships, through alcohol and drug abuse, unemployment,
clinical depression and other forms of mental illness.
Because of this, suicide is often used as a proxy indicator of
the mental health status of a population. However, the
number of suicides in certain countries may be underreported because of the stigma that is associated with the
act, or because of data issues associated with reporting
criteria (see “Definition and comparability”).
Suicide is a significant cause of death in many
EU member states, with approximately 60 000 such deaths
in 2010. Rates of suicide were low in southern European
countries – Cyprus, Greece, Italy, Malta, Portugal and Spain –
as well as in the United Kingdom, at eight deaths or less per
100 000 population (Figure 1.7.1). They were highest in the
Baltic States and Central Europe; in Estonia, Hungary, Latvia,
Lithuania and Slovenia there were more than 17 deaths per
100 000 population. There is more than a ten-fold difference
between Lithuania and Greece, the countries with the lowest
and highest death rates.
(Figure 1.7.3). The high suicide rates in Lithuania have been
associated with a wide range of factors including rapid
socio-economic transition, increasing psychological and
social insecurity and the absence of a national suicide prevention strategy. Similarly in Hungary, societal factors
including employment and socio-economic circumstances,
as well as individual demographic and clinical factors have
been cited as determinants of suicide (Almasi et al., 2009).
Mental health problems are rising in the European
Union. The European Pact for Mental Health and Wellbeing, launched in 2008, recognised the prevention of
depression and suicide as one of five priority areas. It called
for action through improved training of mental health
professionals, restricted access to potential means for
suicide, measures to raise mental health awareness, measures to reduce risk factors for suicide such as excessive
drinking, drug abuse and social exclusion, depression and
stress, and provision of support mechanisms after suicide
attempts and for those bereaved by suicide, such as
emotional support helplines (EC, 2009b).
Death rates from suicide are four-to-five times greater
for men than for women across the European Union,
although in those countries with the highest rates, male
deaths are up to seven times as common (Figure 1.7.1). The
gender gap is narrower for attempted suicides, reflecting
the fact that women tend to use less fatal methods than
men. Suicide is also related to age, with young people aged
under 25 and elderly people especially at risk. While
suicide rates among the latter have generally declined over
the past two decades, little progress has been observed
among younger people.
The World Health Organization defines “suicide” as
an act deliberately initiated and performed by a person
in the full knowledge or expectation of its fatal outcome.
Comparability of suicide data between countries is
affected by a number of reporting criteria, including
how a person’s intention of killing themselves is ascertained, who is responsible for completing the death
certificate, whether a forensic investigation is carried
out, and the provisions for confidentiality of the cause
of death. Caution is required therefore in interpreting
variations across countries.
Since 1995, suicide rates have decreased in many
countries, with pronounced declines of 40% or more in
Bulgaria, Estonia and Latvia (Figure 1.7.2). Despite this
progress, Estonia and Latvia still have among the highest
suicide rates in Europe. On the other hand, death rates
from suicides have increased since 1995 in Malta, Poland
and Portugal, as well as Iceland, although rates in Iceland
and Malta are dependent on small numbers. Iceland, Malta
and Portugal still remain below the EU average. There is no
strong evidence that national suicide rates have increased
since the onset of the economic crisis.
Database.
Suic ide rate s in Lithu ania increas ed s te adily
after 1990, especially among young men, peaking in 1996
28
Deaths from suicide are classified to ICD-10
Codes X60-X84. Mathers et al. (2005) have provided a
general assessment of the coverage, completeness
and reliability of data on causes of death.
1.7. SUICIDE
1.7.1. Suicide mortality rates, 2010 (or nearest year)
Males
Females
Total population
Males and females
Greece
Cyprus
Italy
Spain
United Kingdom
Malta
Portugal
Netherlands
Bulgaria
Luxembourg
Denmark
Germany
Slovak Republic
Ireland
Romania
EU27
Sweden
Austria
Czech Republic
France
Poland
Belgium
Finland
Slovenia
Estonia
Latvia
Hungary
Lithuania
3.0
3.6
5.4
5.8
6.4
7.4
8.2
8.8
9.3
9.7
9.9
9.9
10.8
11.1
11.2
12.3
12.3
12.8
12.8
14.9
15.4
16.8
16.8
17.2
18.3
20.7
21.7
31.5
11.5
14.7
15.1
35
30
25
20
15
10
5
5.9
1.3
8.8
2.3
9.4
2.5
10.1
2.9
0.7
14.1
13.5
3.8
12.7
5.2
15.3
4.0
15.8
4.0
4.3
15.8
4.7
15.6
19.4
3.0
17.7
4.5
19.9
3.2
20.7
4.7
17.7
7.1
20.9
5.7
22.1
4.1
23.3
7.4
28.0
3.8
25.0
9.1
25.7
8.1
29.3
6.1
33.9
5.3
37.6
6.7
37.4
8.5
58.5
8.8
FYR of Macedonia
Iceland
Norway
Croatia
Switzerland
8.0
11.5
5.2
0.9
0
12.6
3.9
18.3
16.5
4.6
6.5
24.3
6.6
21.8
9.1
0
10
20
30
40
50
60
1 2 http://dx.doi.org/10.1787/888932703259
1.7.2. Change in suicide rates,
Estonia
Latvia
Bulgaria
Denmark
Slovenia
Austria
Finland
Lithuania
Luxembourg
EU25
Hungary
Germany
Italy
France
Czech Republic
Spain
Slovak Republic
Belgium
Sweden
United Kingdom
Greece
Netherlands
Ireland
Poland
Portugal
Malta
1.7.3. Trends in suicide rates,
selected European countries, 1995-2010
-55
Estonia
-44
-40
-38
-37
-37
-36
-34
-32
-31
-29
-29
Greece
Lithuania
EU25
50
40
-22
-21
-20
-19
-16
-15
-13
30
20
-9
-6
-4
-3
5
9
61
Switzerland
Norway
Iceland
10
-18
-3
10
-80
-40
0
40
80
Percentage change
1 2 http://dx.doi.org/10.1787/888932703278
0
1995
2000
2005
2010
1 2 http://dx.doi.org/10.1787/888932703297
29
1.8. INFANT MORTALITY
Infant mortality, the rate at which babies and children
of less than one year of age die, reflects the effect of economic and social conditions on the health of mothers and
newborns, as well as the effectiveness of health systems.
In most European countries, infant mortality is low
and there is little difference in rates (Figure 1.8.1). A small
group of countries, however, have infant mortality rates
above five deaths per 1 000 live births. In 2010, rates ranged
from a low of less than three deaths per 1 000 live births
in Nordic countries (with the exception of Denmark),
Portugal, Slovenia and the Czech Republic, up to a high
of 9.8 and 9.4 in Romania and Bulgaria respectively, and
13.6 in Turkey. Infant mortality rates were also relatively
high (more than six deaths per 1 000 live births) in Serbia
and the Former Yugoslav Republic of Macedonia. The
average across the 27 EU member states in 2010 was
4.2 deaths per 1 000 live births. Infant mortality rates tend
to be higher than the EU average in central European
countries, with the exceptions of the Czech Republic and
Slovenia, both of which have had consistently lower rates.
Around two-thirds of the deaths that occur during the
first year of life are neonatal deaths (i.e. during the first
four weeks). Birth defects, prematurity and other conditions arising during pregnancy are the principal factors
contributing to neonatal mortality in developed countries.
With an increasing number of women deferring childbearing and the rise in multiple births linked with fertility
treatments, the number of pre-term births has tended
to increase (see Indicator 1.9 “Infant health: Low birth
weight”). In a number of higher-income countries, this has
contributed to a leveling-off of the downward trend in
infant mortality rates over the past few years. For deaths
beyond one month (post neonatal mortality), there tends to
be a greater range of causes – the most common being SIDS
(Sudden Infant Death Syndrome), birth defects, infections
and accidents.
All European countries have achieved remarkable
progress in reducing infant mortality rates from the levels
of 1970, when the average was 25 deaths per 1 000 live
births, to the current average of 4.2 (Figure 1.8.1). This
equates to a cumulative reduction of over 80% since 1970.
Portugal has seen its infant mortality rate reduced by 7.5%
per year on average since 1970, moving from the country
30
with the highest rate in Europe to an infant mortality rate
among the lowest in Europe in 2010 (Figure 1.8.2). Large
reductions in infant mortality rates have also been
observed in Slovenia, Italy, Cyprus and Greece, as well as
the Former Yugoslav Republic of Macedonia and Croatia.
The reduction in infant mortality rates has been slower in
Bulgaria, Latvia and the Netherlands, although rates in the
latter two countries were low in 1970. Infant mortality rates
in Poland declined rapidly in the early 1990s to approach
the EU average.
Numerous studies have used infant mortality rates as a
health outcome to examine the effect of a variety of medical
and non-medical determinants of health (e.g. OECD, 2010a).
Although most analyses show an overall negative relationship between infant mortality and health spending, the fact
that some countries with a high level of health expenditure
do not exhibit low levels of infant mortality suggests that
more health spending is not necessarily required to obtain
better results (Retzlaff-Roberts et al., 2004). A body of research
also suggests that many factors beyond the quality and efficiency of the health system – such as income inequality, the
social environment, and individual lifestyles and attitudes –
influence infant mortality rates (Schell et al., 2007).
The infant mortality rate is the number of deaths of
children under one year of age in a given year,
expressed per 1 000 live births. Neonatal mortality
refers to the death of children under 28 days.
Some of the international variation in infant and
neonatal mortality rates may be due to variations
among countries in registering practices of premature
infants. Most countries have no gestational age or
weight limits for mortality registration. Minimal
limits exist for Norway (to be counted as a death
following a live birth, the gestational age must exceed
12 weeks) and in the Czech Republic, the Netherlands
and Poland a minimum gestational age of 22 weeks
and/or a weight threshold of 500 grams is applied.
1.8. INFANT MORTALITY
1.8.1. Infant mortality rates, 2010 and decline 1970-2010
Decline 1970-2010 (or nearest year)
Finland
Portugal
Slovenia
Sweden
Czech Republic
Spain
Cyprus
Estonia
Denmark
Germany
Italy
Luxembourg
France
Belgium
Greece
Ireland
Netherlands
Austria
EU27
Lithuania
United Kingdom
Poland
Hungary
Malta
Latvia
Slovak Republic
Bulgaria
Romania
2.3
2.5
2.5
2.5
2.7
3.2
3.3
3.3
3.4
3.4
3.4
3.4
3.5
3.6
3.8
3.8
3.8
3.9
4.2
4.3
4.3
5.0
5.3
5.5
5.7
5.7
9.4
9.8
7.5
5.5
3.6
4.9
4.6
5.0
4.1
3.5
4.6
5.3
4.9
4.0
4.3
5.0
4.0
3.0
4.6
4.3
3.7
3.6
4.8
4.7
4.0
2.8
3.7
2.6
4.0
Iceland
Norway
Switzerland
Croatia
Montenegro
Serbia
FYR of Macedonia
Turkey
2.2
2.8
3.8
4.4
5.7
6.7
7.6
13.6
15
10
Deaths per 1 000 live births
4.3
5
0
4.4
3.4
3.4
5.0
n.a.
n.a.
5.9
n.a.
0
2
4
6
8
Average annual rate of decline (%)
1 2 http://dx.doi.org/10.1787/888932703316
1.8.2. Infant mortality rates, selected European countries, 1970-2010
Finland
Portugal
Slovenia
EU27
Deaths per 1 000 live births
60
50
40
30
20
10
0
1970
1975
1980
1985
1990
1995
2000
2005
2010
1 2 http://dx.doi.org/10.1787/888932703335
31
1.9. INFANT HEALTH: LOW BIRTH WEIGHT
Low birth weight – defined as a newborn weighing less
than 2 500 grams – is an important indicator of infant
health because of the close relationship between birth
weight and infant morbidity and mortality. There are two
categories of low birth weight babies: those occurring as a
result of restricted foetal growth and those resulting from
pre-term birth. Low birth weight infants have a greater risk
of poor health or death, require a longer period of hospitalisation after birth, and are more likely to develop significant disabilities (UNICEF and WHO, 2004).
Risk factors for low birth weight include adolescent
motherhood, a previous history of low weight births,
engaging in harmful behaviours such as smoking and
excessive alcohol consumption, having poor nutrition, a
background of low parental socio-economic status, and
having had in-vitro fertilisation treatment.
One-in-fifteen babies born in the European Union
in 2010 – or 6.9% of all births – weighed less than
2 500 grams at birth. A north-south gradient is evident for
low birth weight in Europe, in that the Nordic countries and
Baltic States – including Estonia, Finland, Iceland, Latvia,
Lithuania and Sweden – reported the smallest proportions
of low weight births, with less than 5.0% of live births so
defined. Countries from Southern Europe including Cyprus,
Greece, Portugal and Spain, as well as Bulgaria, Hungary,
Romania, Turkey and the Former Yugoslav Republic of
Macedonia, are at the other end of the scale with rates of
low birth weight infants above 7.5%. The proportion of low
birth weight among European countries varies by a factor
of almost three (Figure 1.9.1).
Since 1980, and more so after 1995, the prevalence of
low birth weight infants has increased in most European
countries (Figure 1.9.1). There are several reasons for this
rise. The number of multiple births, with the increased
risks of pre-term births and low birth weight, has risen
steadily, partly as a result of the rise in fertility treatments.
Other factors which may have influenced the rise in low
birth weight are older age at childbearing and increases in
the use of delivery management techniques such as induction of labour and caesarean delivery, which have increased
the survival rates of low birth weight babies.
Greece, Malta, Portugal and Spain have seen great
increases in the past three decades (Figure 1.9.2). As a
result, the proportion of low birth weight babies in these
countries is now above the European average. Low birth
32
weight proportions in Poland and Hungary have declined
over the same time period. Little change occurred in
Nordic countries including Denmark, Finland, Iceland and
Sweden, although a rise was observed in Norway.
Figure 1.9.3 shows some correlation between the
percentage of low birth weight infants and infant mortality
rates. In general, countries reporting a low proportion of
low birth weight infants also report relatively low infant
mortality rates. This is the case for instance for the Nordic
countries. Greece, however, is an exception, reporting a
high proportion of low birth weight infants but a low infant
mortality rate.
Despite the widespread use of a 2 500 grams limit for
low birthweight, physiological variations in size occur
among different countries and population groups, and
these need to be taken into account when interpreting
differences (EURO-PERISTAT, 2008). Some populations may
have lower than average birth weights than others because
of genetic differences. Comparisons of different population
groups within countries show that the proportion of low
birth weight infants is also influenced by non-medical
factors. In England and Wales, mothers’ marital status at
birth, being a mother from non-White ethnic group and
living in a deprived area were associated with low birthweight (Bakeo and Clarke, 2006). In Greece, marital status,
education, maternal occupation and region of residence
were significant factors (Lekea-Karanika et al., 1999).
Low birth weight is defined by the World Health
Organization (WHO) as the weight of an infant at birth
of less than 2 500 grams (5.5 pounds), irrespective of
the gestational age of the infant. This is based on
epidemiological observations regarding the increased
risk of death to the infant and serves for international
comparative health statistics. The number of low
weight births is then expressed as a percentage of
total live births.
The majority of the data comes from birth registers.
A small number of countries supply data for selected
regions or from surveys.
1.9. INFANT HEALTH: LOW BIRTH WEIGHT
1.9.1. Low birth weight infants, 2010 and change 1980-2010
Change 1980-2010 (or nearest year)
Estonia
Sweden
Finland
Lithuania
Latvia
Ireland
Denmark
Poland
Slovenia
France
Netherlands
Luxembourg
EU27
Belgium
Germany
United Kingdom
Austria
Italy
Malta
Czech Republic
Spain
Romania
Portugal
Hungary
Slovak Republic
Bulgaria
Greece
Cyprus
4.0
4.2
4.3
4.7
4.9
5.0
5.2
6.0
6.2
6.4
6.5
6.7
6.9
6.9
6.9
6.9
7.0
7.0
7.3
7.7
7.7
8.0
8.2
8.6
9.0
9.1
10.0
11.7
0.0
10.3
n.a.
n.a.
25.0
-11.2
-21.1
6.9
23.1
62.5
6.3
21.7
23.2
25.5
3.0
22.8
25.0
73.8
30.5
108.4
5.7
78.3
-17.3
52.2
49.2
69.5
n.a.
Iceland
Croatia
Montenegro
Norway
Serbia
Switzerland
FYR of Macedonia
Turkey
3.6
4.5
5.2
5.4
5.7
6.6
7.8
11.0
15
10
Percentage of newborns weighing less than 2 500 g
n.a.
5
0
5.9
n.a.
n.a.
42.1
n.a.
29.4
n.a.
n.a.
-50
0
50
100
150
% change over period
Source: OECD Health Data 2012; WHO European Health for All Database.
1 2 http://dx.doi.org/10.1787/888932703354
1.9.2. Trends in low birth weight infants,
selected European countries, 1980-2010
Finland
Greece
Spain
1.9.3. Low birth weight and infant mortality,
EU27
Infant mortality (deaths per 1 000 live births)
15
Percentage of newborns weighing less than 2 500 g
12
TUR
R 2 = 0.20
10
12
8
9
ROU
6
6
4
3
2
1980
BGR
MKD
SRB
MLT
GBR
LVA
MNE NLD
SVK
CHE
LTU POL
HUN
AUT
HRV
IRL
BEL
DNK
EST
SWE
ITA ESP
PRT
FIN NOR
ISL
CZE
SVN
LUX DEU
FRA
GRC
CYP
0
1985
1990
1995
2000
2005
2010
1 2 http://dx.doi.org/10.1787/888932703373
2
4
6
8
10
12
Low birth weight (%)
1 2 http://dx.doi.org/10.1787/888932703392
33
1.10. SELF-REPORTED HEALTH AND DISABILITY
Most European countries conduct regular health
surveys which allow respondents to report on different
aspects of their health. A commonly-asked question relates
to self-perceived health status, of the type: “How is your
health in general?”. Despite the subjective nature of this
question, indicators of perceived general health have been
found to be a good predictor of people’s future health care
use and mortality (DeSalvo et al., 2005; Bond et al., 2006).
For the purpose of international comparisons however, cross-country differences in perceived health status
are difficult to interpret because responses may be affected
by social and cultural factors. Since they rely on the subjective views of the respondents, self-reported health status
may reflect cultural biases or other influences. Also, since
the elderly report poor health more often than younger
people, countries with a larger proportion of aged persons
will also have a lower proportion of people reporting good
or very good health. In addition, the institutionalised
population, which has poorer health than the rest of the
population, is often not surveyed.
With these limitations in mind, in almost all European
countries a majority of the adult population rate their
health as good or very good (Figure 1.10.1). In Ireland and
Sweden, as well as Switzerland, more than eight out of ten
people report good or very good health. Across the
European Union, two-thirds (67%) of all adults rated their
health as good or better, with France, Germany and Italy
close to this average. Adults in central European countries,
along with Portugal, report the lowest rates of good or very
good health. In Croatia, Estonia, Hungary, Latvia, Lithuania,
Poland and Portugal, less than 60% of all adults consider
themselves to be in good health. These differences, however, do not necessarily mean that the general health of
people in Ireland or Sweden is objectively better than that
of citizens in Latvia or Portugal (Baert and de Norre, 2009).
In all European countries, men are more likely than
women to rate their health as good or better, with the
largest differences in Portugal and Bulgaria. Unsurprisingly,
people’s rating of their own health tends to decline with
age. In many countries there is a particularly marked
decline in a positive rating of one’s own health after age 45
and a further decline after age 65. People who are unemployed, retired or inactive more often report bad or very bad
health (Baert and de Norre, 2009). People with a lower level
of education or income do not rate their health as
positively as people with higher levels (OECD, 2012a;
Mackenbach et al., 2008).
Another common health interview survey question
asks whether respondents had any long-standing illnesses
or health problems. Three-in-ten adults in EU member
states reported having illnesses or health problems
34
(Figure 1.10.1). Adults in Finland and Estonia were more
likely to report having illnesses or health problems, while
these conditions were less commonly reported in Romania
and Bulgaria. Women reported long-standing illnesses or
health problems more often than men (an average of
33% vs. 28% across EU member states), with the gender
divide greatest in Finland and Latvia. Reporting increased
with age, from an average of 7% of young people aged
16-24 years, to 73% of older persons aged 85 years or more.
There is a moderate negative association between adults
reporting good/very good health, and reporting a longstanding illness or health problem (R2 = –0.28).
When adults were asked whether they had been limited
in their usual daily activities because of a health problem
– which is one definition of disability – 24% answered that
they had, with 8% of respondents “strongly limited” and
17% “limited to some extent” (Figure 1.10.2). Adults most
commonly reported activity limitation in Estonia, Finland,
Germany, Latvia, Portugal, Slovenia and the Slovak Republic,
as well as Croatia (30% or more of respondents), and less so in
Malta and Sweden (less than 15%). Severe activity limitation
was more prevalent in Germany, Slovenia and the Slovak
Republic, as well as Croatia (10% or more of respondents), and
less so in Bulgaria and Malta (less than 5%). Adults with
activity limitations were also less likely to report good or very
good health (R2 = 0.53).
Self-reported health reflects people’s overall perceptions of their own health, including both physical and
psychological dimensions. Typically ascertained
through health interview surveys, respondents are
asked a number of questions on their health and
functioning. The three questions used in the EU-SILC
survey, and some other national surveys are: i) “How is
your health in general? Is it very good, good, fair, bad,
very bad”; ii) “Do you have any longstanding illness or
health problem which has lasted, or is expected to last
for six months or more?”; and iii) “For at least the past
six months, have you been hampered because of a
health problem in activities people usually do? Yes,
strongly limited/Yes, limited/No, not limited”.
Persons in institutions are not surveyed. Caution is
required in making cross-country comparisons of
perceived general health, since people’s assessment
of their health is subjective and can be affected by
their social and cultural backgrounds.
1.10. SELF-REPORTED HEALTH AND DISABILITY
1.10.1. Adults’ self-reported health status, 2010
Good or very good health
Long-standing illness or health problem
Ireland
Sweden
United Kingdom
Netherlands
Cyprus
Greece
Luxembourg
Belgium
Spain
Denmark
Romania
Austria
Finland
Malta
France
Bulgaria
EU27
Italy
Germany
Slovak Republic
Czech Republic
Slovenia
Poland
Hungary
Estonia
Lithuania
Portugal
Latvia
83
80
79
78
76
76
75
73
72
71
71
70
69
68
67
67
67
67
65
63
62
60
58
55
53
52
49
49
78
77
66
46
60
31
35
33
33
21
22
26
28
27
19
35
44
28
37
19
30
22
36
30
29
36
33
36
43
27
30
34
Switzerland
Iceland
Norway
Turkey
Croatia
82
100
90
80
70
% of population aged 16 and over
28
50
40
34
29
34
n.a.
37
30
10
20
30
40
50
Source: EU Statistics on Income and Living Conditions survey; OECD Health Data 2012.
1 2 http://dx.doi.org/10.1787/888932703411
1.10.2. Adults reporting a limitation in usual activities, 2010
Limited strongly
Limited to some extent
11.7
12.1
23.7
17.2
9.6
5.7
23.6
23.5
22.9
23.3
22.4
20.0
5.9
10.2
21.6
10.5
9.4
8.3
7.1
7.9
8.7
9.4
19.0
21.9
18.8
15.8
17.6
16.2
15.1
6.9
10.5
12.0
12.6
22.1
7.0
7.9
9.6
7.5
17.0
7.9
16.0
16.9
7.9
5.6
15.5
6.0
6.6
6.2
14.3
9.2
6.0
8.2
10.8
8.4
11.7
10
8.9
14.0
7.3
3.8
6.1
3.8
5.2
20
11.2
30
5.5
40
ay
S w el an
it z d
er
la
nd
Cr
oa
tia
rw
Ic
No
M
al
Sw ta
ed
e
Bu n
lg
ar
ia
Ir e
la
nd
Cy
pr
us
Gr
Lu
ee
xe
c
m e
bo
ur
g
Un
i te
It a
d
l
Ki
y
ng
d
L i om
Cz
t
e c hu a
n
h
Re i a
pu
bl
ic
Sp
ai
Be n
lg
iu
m
Po
la
nd
EU
De 2 7
nm
ar
k
Fr
an
c
Ro e
Ne man
i
th
er a
la
nd
Au s
st
r
Hu i a
ng
ar
Es y
to
ni
a
La
tv
ia
Fi
nl
a
Po nd
r tu
g
Sl Ge a l
r
ov
ak man
Re y
pu
b
Sl lic
ov
en
ia
0
Source: EU Statistics on Income and Living Conditions survey.
1 2 http://dx.doi.org/10.1787/888932703430
35
1.11. INCIDENCE OF SELECTED COMMUNICABLE DISEASES
Communicable diseases such as chlamydia, pertussis
and hepatitis B still pose major threats to the health of
European citizens. Chlamydia is the most common sexually
transmitted infection in Europe. Three-quarters of all cases
are reported among young people aged 15-24 years, and
numbers are steadily increasing. It can be controlled
through prevention, reducing risk behaviour, early detection
and effective management. Pertussis (or whooping cough) is
highly infectious, and is caused by the bacterium Bordetella
pertussis. The disease derives its name from the sound made
from the intake of air after a cough. Hepatitis B is an infection of the liver caused by the hepatitis B virus. The virus is
transmitted by contact with blood or body fluids of an
infected person. A small proportion of infections become
chronic, and these people are at high risk of death from
cancer or cirrhosis of the liver. Protection against pertussis
and hepatitis B is available through vaccination (see
Indicator 4.10 “Childhood vaccination programmes”).
Over 285 000 chlamydia cases were reported annually
in EU member states during 2007-09, with almost all infections reported by five countries (the United Kingdom, and
the Nordic countries of Denmark, Finland, Norway and
Sweden). The true number of chlamydia cases is likely to be
much higher, since the infection is liable to underreporting
and asymptomatic disease. Confirmed case rates were
highest in Iceland (655 per 100 000 population), Denmark
(514), Sweden (458), the United Kingdom (290) and Finland
(258) (Figure 1.11.1). Between 2006 and 2009, incidence of
reported and confirmed cases increased by 42%, although
much of this was a result of improved case detection in a
number of countries (ECDC, 2011).
Over 14 000 pertussis cases were reported annually
among EU member states in 2007-09, with an overall incidence of 5 per 100 000 population (Figure 1.11.2). The highest
incidences were reported in Norway (104 cases per
100 000 population), the Netherlands (44), Estonia (38) and
Slovenia (17). Most cases were reported from the Netherlands,
Norway and Poland, which together contributed almost
three-quarters (71%) of all cases reported in 2009. Pertussis
incidence has more than halved since 1991-93, when the
average rate among EU member states was 11.3 notified cases
per 100 000 population.
Two-thirds of all pertussis cases in 2008 occurred
among children aged 5-14 years of age, although the
disease may be underdiagnosed in adolescents and adults.
The highest incidence occurred among infants aged less
than one year, many of whom are too young to be vaccinated, and children aged 10-14 years, who may have not
36
had a full course of vaccination, or who may have lost their
immunity. Vaccination status was known in only half of all
reported cases, but of these 21% were unvaccinated
(EUVAC.NET, 2010).
Around 6 000 hepatitis B cases were reported annually
in EU member states during 2007-09. The highest incidence
rates occurred among Iceland (13.8 notified cases per
100 000 population, including both acute and chronic cases),
Bulgaria (8.2) and Latvia (6.3) (Figure 1.11.3). The EU average
was 2.0 cases per 100 000 population. The notification
rate has declined since 1991-93, when it was 8.3 cases per
100 000 population on average. Hepatitis B infection is more
common in the southern parts of Eastern and Central
Europe, and low in prevalence in most of Western Europe.
Around twice as many cases of hepatitis B occurred among
males than females in 2009, with the majority reported in
the age group 25-44 years (49% of the total), followed by
15-24 year-olds. The disease has the characteristics of both a
sexually transmitted and a blood-borne disease, although
the disease pattern and risk groups differ widely across
Europe (ECDC, 2011). Enhanced surveillance systems will
provide the better information which is needed to monitor
the disease.
The European Centre for Disease Prevention and
Control (ECDC) was set up in 2005 to assist the European
Union by identifying and assessing the risk of current and
emerging threats to human health posed by infectious
diseases.
Although notification of chlamydia is compulsory
in most European countries, national surveillance
systems for sexually transmitted infections consist of
voluntary, sentinel or laboratory systems, and often
do not provide full country coverage. Countries also
differ in reporting systems, diagnosis, testing and
screening programmes. Underreporting is likely.
Mandatory notification systems for pertussis and
hepatitis B also exist in most European countries,
although again case definitions, laboratory confirmation requirements and reporting systems may differ.
Pertussis notification was voluntary in Belgium and
France, and France had a sentinel surveillance system.
1.11. INCIDENCE OF SELECTED COMMUNICABLE DISEASES
1.11.1. Notification rate of chlamydia infection, 2007-09
Denmark
1.11.2. Notification rate of pertussis, 2007-09
Netherlands
514
Sweden
United Kingdom
Finland
258
6.1
EU26
5.4
Sweden
5.2
Poland
4.7
94
Netherlands
55
Latvia
Lithuania
3.0
Slovak Republic
2.5
37
Bulgaria
2.2
25
Denmark
1.8
19
Belgium
1.7
Ireland
1.4
Belgium
Malta
Lithuania
11
Austria
7.9
Czech Republic
116
EU21
17.2
Finland
166
Ireland
37.9
Slovenia
290
Estonia
43.5
Estonia
458
9
Austria
1.3
United Kingdom
1.1
Slovenia
7
Italy
1.0
Hungary
7
Cyprus
0.7
Slovak Republic
3
Luxembourg
0.5
Poland
2
Greece
2
Spain
1
Portugal
0.5
Latvia
0.4
Hungary
0.4
Spain
0.3
0.1
Romania
1
France
Luxembourg
0
Greece
0.1
Cyprus
0
Romania
0.0
Malta
0.0
Iceland
655
Norway
Norway
483
0
200
400
103.5
Iceland
600
800
Per 100 000 population
0.0
0
Source: ECDC (2011).
25
50
75
100
125
1 2 http://dx.doi.org/10.1787/888932703449
1 2 http://dx.doi.org/10.1787/888932703468
1.11.3. Notification rate of hepatitis B, 2007-09
15
13.8
12
9
8.2
6.3
6
3.8
3.7
3.5
3.1
2.7
3
2.3
2.2
2.0
1.8
1.6
1.5
2.0
1.5
1.3
1.2
1.1
1.1
1.0
0.8
0.8
0.8
0.7
0.6
0.6
0.5
0.2
0.2
ay
d
an
rw
el
No
Ic
ria
ce
st
an
Au
Fr
l
nd
ga
la
Po
Po
r tu
d
ce
ee
Gr
y
Fi
nl
an
m
ar
ng
Hu
Be
lg
iu
ta
y
al
M
m
an
do
rm
ng
Ki
Un
i te
d
Ge
s
us
pr
Cy
ia
th
er
la
nd
ly
en
ov
Sl
Ne
n
ai
It a
Sp
en
nd
la
Ir e
ic
27
ed
Sw
EU
a
ni
bl
pu
ua
th
Sl
ov
ak
Li
Re
a
ic
ni
bl
to
pu
Es
Re
h
ec
Cz
Ro
m
ur
bo
m
xe
an
g
ia
k
ia
ar
nm
Lu
De
tv
La
Bu
lg
ar
ia
0
1 2 http://dx.doi.org/10.1787/888932703487
37
1.12. HIV/AIDS
The first cases of Acquired Immunodeficiency
Syndrome (AIDS) were diagnosed more than 30 years ago.
The onset of AIDS is caused as a result of HIV (human
immunodeficiency virus) infection and can manifest itself
as any number of different diseases, such as pneumonia
and tuberculosis, as the immune system is no longer able
to defend the body, leaving it susceptible to opportunistic
infections and tumors. There is a time lag between
HIV infection, AIDS diagnosis and death, which can be any
number of years depending on the treatment administered.
Despite worldwide research, there is no cure currently
available. HIV remains a major public health issue in
Europe, with continuing transmission.
In 2010, almost 27 000 cases of newly diagnosed HIV
infection were reported by EU member states, and another
1 600 cases in the six EU candidate countries, Norway and
Switzerland. Estonia had the highest rate of new cases, at
27.8 per 100 000 population, followed by Belgium, Latvia and
the United Kingdom, all at over ten (Figure 1.12.1). On average
across EU member states, 6.2 new cases of HIV infection were
diagnosed per 100 000 population in 2010. One quarter of
cases were female, although the ratio varied greatly between
countries, from Hungary (16 male cases for each female case)
to Sweden (two). Approximately 800 000 persons were living
with HIV infection in the European Union in 2010. The
predominant mode of transmission of HIV was through men
having sex with men (38%), followed by heterosexual contact
(24%). However, in certain countries injecting drug use is also
a common mode. Approximately 75% of heterosexually
acquired HIV infection in Western and Central Europe is
among migrants.
The number of newly reported cases of AIDS in
EU member states in 2010 was 4 643, representing an
average incidence rate of 1.1 per 100 000 population
(Figure 1.12.1). Following the first reporting of AIDS in the
early 1980s, the number of cases rose rapidly to reach an
average of almost four new cases per 100 000 population
across EU member states at its peak in the middle of
the 1990s, four times the current incidence rate. Public
awareness campaigns contributed to steady declines in
reported cases through the second half of the 1990s. In
addition, the development and greater availability of antiretroviral drugs, which reduce or slow down the development of the disease, led to a sharp decrease in incidence
from 1996 onward.
The highest AIDS incidence rates among EU member
states in 2010 were reported in Latvia, followed by Portugal
and Spain, at two or more cases per 100 000 population.
38
Spain had the highest incidence rates in the first decade
following the outbreak, although there was a sharp decline
from 1994 onwards. Incidence rates in Portugal peaked
somewhat later, towards the end of the 1990s. AIDS incidence rates in Latvia increased rapidly to the mid-2000s
(Figure 1.12.2). Central European countries such as
Bulgaria, the Czech and Slovak Republics, Hungary, Poland
and Slovenia report the lowest incidence rates of AIDS,
although incomplete reporting may lead to underestimates
(ECDC and WHO Regional Office for Europe, 2011).
In recent years, the number of AIDS cases reported in
the EU has steadily declined. However, continuing transmission of HIV and increases in reported rates in some
countries reinforce the need for evidence-based interventions which are adapted to the situation of each country.
A European Commission Communication details the
policy priorities regarding HIV in Europe for 2009-13. The
main objectives are to reduce new HIV infections across all
European countries by 2013; improve access to prevention,
treatment, care and support; and to improve the quality of
life of people affected by HIV/AIDS in the European Union
and neighbouring countries. The Communication also
highlights priority regions and priority groups and emphasises the improvement of knowledge, including surveillance, monitoring, evaluation and research (ECDC, 2012).
The incidence rates of HIV (human immunodeficiency virus) and AIDS (acquired immunodeficiency
s y nd ro m e) a re t h e nu m b er o f n ew ca s e s p er
100 000 population at year of diagnosis. However,
since newly reported HIV diagnoses may also include
persons infected several years ago, the data do not
represent real incidence. Underreporting and underdiagnosis also affect incidence rates, and could be as
much as 40% in some countries (ECDC, 2011).
Note that data for recent years are provisional due
to reporting delays, which can sometimes be for
several years. Reporting is voluntary in some
countries. Others report regional data only.
1.12. HIV/AIDS
1.12.1. HIV and AIDS incidence rates in 2010
HIV incidence
AIDS incidence
Estonia
Latvia
Belgium
United Kingdom
Portugal
Spain
Luxembourg
Ireland
EU27
France
Netherlands
Italy
Sweden
Cyprus
Denmark
Greece
Lithuania
Malta
Finland
Germany
Poland
Bulgaria
Hungary
Czech Republic
Slovenia
Romania
Slovak Republic
Austria
27.8
12.2
11.0
10.7
8.9
8.9
8.8
7.4
6.2
6.1
6.0
5.9
5.2
5.1
5.0
4.7
4.6
4.1
3.6
3.6
2.4
2.2
1.8
1.7
1.7
0.7
0.5
n.a.
7.6
5.3
2.3
2.0
1.5
0.7
0.2
10
5.5
0.7
1.0
3.3
2.0
0.8
0.9
1.1
1.0
1.4
1.2
0.7
1.2
0.8
0.8
1.0
1.4
0.6
0.3
0.4
0.4
0.3
0.2
0.3
0.7
0.0
0.6
Switzerland
Iceland
Norway
Montenegro
Serbia
Croatia
Turkey
FYR of Macedonia
7.8
30
20
New cases per 100 000 population
1.9
0
1.9
0.3
0.5
1.0
0.6
0.4
0.1
0.4
0
2
4
6
Source: ECDC and WHO Regional Office for Europe (2011).
1 2 http://dx.doi.org/10.1787/888932703506
1.12.2. Trends in AIDS incidence rates, selected EU member states, 2000-10
Italy
Latvia
Portugal
EU21
12
9
6
3
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Source: ECDC and WHO Regional Office for Europe (2011).
1 2 http://dx.doi.org/10.1787/888932703525
39
1.13. CANCER INCIDENCE
In 2008, an estimated 2.4 million new cases of cancer
(excluding non-melanoma skin cancers) were diagnosed in
EU member states (Ferlay et al., 2010), and of these 55%
occurred among males and 45% among females. The most
commonly diagnosed cancers were prostate, colorectal,
breast and lung cancer. The risk of getting cancer before
the age of 75 years was 26.5%, or around one in four. However, because the population of Europe is ageing, the rate of
new cases of cancer is also expected to increase (EC, 2008b).
Large regional inequalities exist in cancer incidence
across European countries. In 2008, the incidence rate for
all cancers combined was highest in Northern and Western
Europe – Belgium, Denmark, France, Iceland, Ireland and
Norway – at over 290 per 100 000 population, but was lower
in some Mediterranean countries such as Cyprus, Greece,
Malta and Turkey, at less than 220. Rates in Italy were above
the EU average of 255 new cases per 100 000 population.
Rates in central European countries varied, being highest in
the Czech Republic and Hungary (around 290), similar to
the EU average in Slovenia and the Slovak Republic (260),
and below average in Bulgaria, Poland and Romania and
other countries.
Cancer incidence rates are higher for men in all EU
member states (Figure 1.13.1). Here too there is great
variation between countries; in Spain and Turkey, male
incidence rates are 60% higher than female rates, whereas
in Cyprus, Denmark and the United Kingdom they are less
than 10% higher. In 2008, the average all cancer incidence
rate among EU member states was 296 per 100 000 males
and 227 per 100 000 females.
In 2008, lung cancer was one of the most common
cancers in Europe, being responsible for around 12% of all
new cancer diagnoses, 16% for males and 7% for females.
Ten of the 15 countries with male rates higher than the EU
average were located in central Europe (Figure 1.13.2). Rates
in Hungary, Poland, Slovenia were higher than 60 per
100 000 population. Male lung cancer incidence rates in
Northern Europe (Finland, Iceland, Norway and Sweden)
and some southern European countries (Cyprus, Malta and
Portugal) were less than 40 per 100 000 population. Among
females, lung cancer incidence was high in Denmark, but
also Hungary, Iceland and the Netherlands, at over 25.
Thirty per cent of all new cancer cases among women
diagnosed in 2008 were cancers of the breast – the most
common form of cancer among women. Incidence rates
were high in Denmark and western European countries
such as Belgium, France, Ireland and the Netherlands, at
over 90 cases per 100 000 population (Figure 1.13.3). Rates
in Central and Southern Europe were lower, with Greece,
Latvia, Lithuania, Poland, Romania and Turkey all reporting
less than 50 new cases per 100 000 population. There has
been an increase in measured incidence rates of breast
40
cancer over the past decade, although death rates have
declined or remained stable. Survival rates have also
increased, due to earlier diagnosis and/or better treatment
(see Indicator 4.8 “Screening, survival and mortality for
breast cancer”).
Prostate cancer has become the most commonly
diagnosed cancer among males in most OECD countries,
particularly among men over 65 years of age. Prostate
cancer comprised one quarter (25%) of all new diagnoses
in 2008. Rates were highest in Belgium, France and Ireland
and northern European countries (Finland, Iceland, Norway
and Sweden) (Figure 1.13.4). Rates were lower in a range of
central and southern European countries, including
Bulgaria, Greece, Romania and Turkey. At least part of the
five-fold difference between countries with the highest and
lowest incidence rates is due to under-registration of
prostate cancer in some countries, as well as the use of
sensitive diagnostic tests for early detection in others
(Ferlay et al., 2007). The rise in the reported incidence of
prostate cancer in many countries since the 1990s is due
largely to the greater use of prostate specific antigen (PSA)
tests, although the use of these has also fluctuated because
of their cost and uncertainty about the long-term benefit to
patients.
Cancer incidence rates are based on numbers of new
cases of cancer registered in a country in a year divided
by the size of the corresponding population. The rates
have been directly age-standardised to Segi’s world
population to remove variations arising from differences in age structures across countries and over time.
The source is GLOBOCAN 2008, at http://globocan.iarc.fr/.
GLOBOCAN estimates for 2008 may differ to actual
incidence for some countries, due to the projection
methods used.
Cancer registration is well established in a majority of
EU member states, although the quality and completeness of cancer registry data may vary. In some
countries, cancer registries only cover subnational
areas. The international comparability of cancer
incidence data can also be affected by differences in
medical training and practice.
The incidence of all cancers is classified to ICD-10
Codes C00-C97 (excluding non-melanoma skin
cancer C44), lung cancer to C33-C34, breast cancer to
C50 and prostate cancer to C61.
1.13. CANCER INCIDENCE
1.13.1. All cancers incidence rates,
males and females, 2008
Males
Cyprus
Greece
Malta
Romania
Bulgaria
Portugal
Sweden
Finland
Austria
United Kingdom
Poland
Estonia
EU27
Latvia
Netherlands
Spain
Italy
Lithuania
Slovenia
Slovak Republic
Luxembourg
Germany
Denmark
Czech Republic
Belgium
Hungary
Ireland
France
Turkey
Montenegro
Serbia
FYR of Macedonia
Iceland
Switzerland
Croatia
Norway
1.13.2. Lung cancer incidence rates,
males and females, 2008
Females
Males
187
190
175
136
233
241
253
200
180
207
267
270
271
275
280
281
286
296
304
306
310
310
317
320
320
324
331
335
325
191
241
240
201
261
186
204
227
193
277
187
252
208
233
223
254
246
349
351
352
356
361
259
276
236
285
255
182
113
231
239
185
205
197
262
306
313
315
266
236
229
338
270
100
Sweden
Cyprus
Portugal
Finland
Malta
Austria
Ireland
United Kingdom
Germany
Denmark
Italy
Luxembourg
EU27
Netherlands
France
Slovak Republic
Greece
Spain
Bulgaria
Romania
Slovenia
Latvia
Czech Republic
Lithuania
Belgium
Estonia
Poland
Hungary
Source: Ferlay et al. (2010).
22
5
29
31
33
6
12
6
37
38
38
17
24
26
42
43
45
46
47
47
48
49
16
35
11
18
15
27
15
11
10
8
9
10
16
7
17
7
18
9
19
52
53
54
55
55
55
56
56
57
64
71
81
31
Iceland
Turkey
Norway
Switzerland
Montenegro
FYR of Macedonia
Croatia
Serbia
200
300
400
Females
18
16
32
29
49
5
35
25
38
17
17
57
58
60
8
14
66
19
0
20
40
60
80
100
1 2 http://dx.doi.org/10.1787/888932703544
1 2 http://dx.doi.org/10.1787/888932703563
1.13.3. Breast cancer incidence rates, females, 2008
1.13.4. Prostate cancer incidence rates, males, 2008
Greece
Romania
Lithuania
Latvia
Poland
Estonia
Slovak Republic
Bulgaria
Hungary
Portugal
Spain
Austria
Slovenia
Cyprus
EU27
Czech Republic
Malta
Sweden
Germany
Luxembourg
Finland
Italy
United Kingdom
Ireland
Netherlands
France
Denmark
Belgium
Greece
Romania
Bulgaria
Hungary
Slovak Republic
Estonia
Poland
Cyprus
Portugal
Malta
Spain
Italy
Slovenia
EU27
United Kingdom
Latvia
Czech Republic
Lithuania
Netherlands
Austria
Denmark
Luxembourg
Germany
Finland
Sweden
Belgium
France
Ireland
41
45
46
48
49
50
53
56
57
60
61
62
65
68
71
71
72
79
82
82
86
86
89
94
99
100
101
109
Turkey
Montenegro
FYR of Macedonia
Serbia
Croatia
Norway
Switzerland
Iceland
28
50
54
57
64
74
89
96
0
25
50
75
100
125
150
1 2 http://dx.doi.org/10.1787/888932703582
16
20
22
32
40
43
44
47
50
51
57
58
63
63
64
66
67
67
68
71
73
75
83
83
96
101
118
126
Turkey
Serbia
Montenegro
FYR of Macedonia
Croatia
Switzerland
Norway
Iceland
15
19
20
21
44
91
104
112
0
25
50
75
100
125
150
Age-standardised rates per 100 000 males
1 2 http://dx.doi.org/10.1787/888932703601
41
1.14. DIABETES PREVALENCE AND INCIDENCE
Diabetes is a chronic metabolic disease, characterised
by high levels of glucose in the blood. It occurs either
because the pancreas stops producing the hormone insulin
(Type 1 diabetes), or through a combination of the pancreas
having reduced ability to produce insulin alongside the
body being resistant to its action (Type 2 diabetes). People
with diabetes are at a greater risk of developing cardiovascular diseases such as heart attack and stroke if the
disease is left undiagnosed or poorly controlled. They also
have elevated risks for sight loss, foot and leg amputation
due to damage to the nerves and blood vessels, and renal
failure requiring dialysis or transplantation.
Diabetes was the principal cause of death of more
than 100 000 persons in EU member states in 2011, and is a
leading cause of death in most developed countries.
However, only a minority of persons with diabetes die from
diseases uniquely related to the condition – in addition,
about 50% of persons with diabetes die of cardiovascular
disease, and 10-20% of renal failure (IDF, 2011).
Diabetes is increasing rapidly in every part of the world,
to the extent that it has now assumed epidemic proportions.
Estimates suggest that more than 6% of the population aged
20-79 years in EU member states, or 30 million people, had
diabetes in 2011, with 42% of diabetic adults aged less than
60 years (IDF, 2011; Whiting et al., 2011). If left unchecked, the
number of people with diabetes in EU member states will
reach more than 35 million in less than 20 years.
Less than 5% of adults aged 20-79 years in Belgium,
Iceland, Luxembourg, Norway and Sweden have diabetes,
according to the International Diabetes Federation. This
contrasts with Portugal, Cyprus and Poland, where 9% or
more of the population of the same age have the disease
(Figure 1.14.1). In Europe, abnormal glucose tolerance
shows little association with affluence, except in a few
countries.
Type 1 diabetes accounts for only 10-15% of all diabetes
cases. It is the predominant form of the disease in younger
age groups in most developed countries. Based on disease
registers and recent studies, the annual number of new
cases of Type 1 diabetes in children aged under 15 years is
high at 25 or more per 100 000 population in Nordic countries (Finland, Norway and Sweden) (Figure 1.14.2). Bulgaria,
Croatia and Switzerland have less than ten new cases per
100 000 population. Alarmingly, there is evidence that Type 1
diabetes is developing at an earlier age among children.
42
The economic impact of diabetes is substantial. Health
expenditure in EU member states in 2011 to treat and
prevent diabetes and its complications was estimated at
USD 110 billion (IDF, 2011). Around one-quarter of medical
expenditure is spent on controlling elevated blood glucose,
another quarter on treating long-term complication of
diabetes, and the remainder on additional general medical
care. Increasing costs reinforce the need to provide quality
care for the management of diabetes and its complications.
In April 2012, the European Diabetes Leadership Forum
brought together a wide range of stakeholders to produce
the Copenhagen Roadmap, outlining initiatives to improve
diabetes prevention, early detection and intervention as well
as management and control (European Diabetes Leadership
Forum, 2012).
Type 2 diabetes is largely preventable. A number of
risk factors, such as overweight and obesity and physical
inactivity are modifiable, and can also help reduce the
complications that are associated with diabetes. But in
most countries, the prevalence of overweight and obesity
also continues to increase (see Indicator 2.7 “Overweight
and obesity among adults”).
The sources and methods used by the International
Diabetes Federation for publishing national prevalence
estimates of diabetes are outlined in their Diabetes
Atlas, 5th edition (IDF, 2011; Guariguata et al., 2011).
Country-level data were derived from studies published up to April 2011, and were only included if they
met several criteria for reliability.
Countries without national data sources are
excluded. Studies from several European countries
only provided self-reported data on diabetes. Studies
only reporting known diabetes were adjusted to
account for undiagnosed diabetes, based on sources
with available data.
Prevalence rates were adjusted to the World Standard
Population to facilitate cross-national comparisons.
1.14. DIABETES PREVALENCE AND INCIDENCE
1.14.1. Prevalence estimates of diabetes, adults aged 20-79 years, 2011
%
10
9.5
9.2
9.8
8.1
7.8
8
6
6.0
5.3
4.9
4.7
4.4
6.0
5.9
5.7
5.6
5.5
5.4
5.4
5.3
5.3
6.9
6.9
6.8
6.5
6.4
6.2
7.2
4.8
4
3.3
2
y
nd
ke
Tu
r
tia
la
oa
Cr
it z
an
rw
el
No
Ic
er
d
ay
l
ga
us
pr
r tu
Cy
Po
ia
Sl
Po
la
nd
a
ov
to
Es
en
ni
ta
ia
al
ar
M
Bu
lg
st
ria
n
Hu
Au
Sp
ai
22
y
ng
nl
Fi
EU
ar
d
ic
an
k
bl
ar
pu
nm
Re
Sw
i te
Sl
Un
ov
d
Ne
ak
De
Fr
an
ce
y
s
an
rm
Ge
th
er
la
nd
m
ly
do
Ki
Be
Gr
ng
ee
It a
m
ce
g
lg
iu
ur
bo
m
xe
Lu
Sw
ed
en
0
Note: The data are age-standardised to the World Standard Population.
Source: IDF (2011).
1 2 http://dx.doi.org/10.1787/888932703620
1.14.2. Incidence estimates of Type 1 diabetes, children aged 0-14 years, 2011
Cases per 100 000 population
60
57.6
50
43.1
40
30
27.9
24.5
22.2
20
10
11.1
10.4
9.4
11.3
12.2
12.1
13.0
18.0
17.3
17.1
15.6
15.5
15.4
14.9
13.6
13.3
13.2
18.6
18.2
14.7
9.2
9.1
ay
No
rw
d
an
nd
la
el
er
it z
Ic
tia
oa
Cr
an
Fi
nl
en
m
do
ed
Sw
d
Sw
i te
d
Ki
ng
nm
ar
k
s
nd
la
er
th
Ne
De
22
EU
y
nd
la
rm
Po
Ge
a
ni
ta
al
ur
to
Es
g
M
m
iu
xe
m
bo
us
lg
pr
Cy
Be
Lu
ic
bl
pu
Re
an
Un
Sl
ov
ak
Au
st
l
ria
n
ga
r tu
Po
ce
ai
an
Fr
Sp
ly
It a
y
Hu
ng
ar
ia
en
Sl
ov
ce
ee
Gr
Bu
lg
ar
ia
0
Source: IDF (2011).
1 2 http://dx.doi.org/10.1787/888932703639
43
1.15. DEMENTIA PREVALENCE
Dementia describes a variety of brain disorders which
progressively lead to brain damage, and cause a gradual
deterioration of the individual’s functional capacity and
social relations. It is one of the most important causes of
disability among the elderly, placing a large burden not only
on sufferers, but also on carers. Alzheimer’s disease is the
most common form of dementia, representing about 60% to
80% of cases. Successive strokes that lead to multi-infarct
dementia are another common cause. Currently, there is no
treatment that can halt dementia, but pharmaceutical drugs
and other interventions can help treat symptoms.
In 2009, there were an estimated 6.8 million people
aged 60 years and over suffering from dementia in
EU member states, accounting for around 6% of the population in that age group, according to estimates by Wimo et al.
(2010) (Figure 1.15.1). France, Italy, Spain, Sweden and
Switzerland had the highest prevalence, with 6.3% to 6.6%
of the population aged 60 years or older. This contrasts
with less than 5% in Bulgaria, the Czech and Slovak
Republics, Malta and Romania, as well as the Former
Yugoslav Republic of Macedonia, Montenegro and Turkey.
Clinical symptoms of dementia usually begin after the
age of 60, and the prevalence increases markedly with age
(Figure 1.15.2). The disease affects more women than men.
In Europe, 14% of men and 16% of women aged 80-84 years
were estimated as having dementia in 2009, compared to
less than 4% among those under 75 years of age (Alzheimer
Europe, 2009). For the very elderly aged 90 years and over,
the figures rise to 31% of men and 47% of women. Earlyonset dementia among people aged younger than 65 years
is rare; they comprise less than 2% of the total number of
people with dementia.
People with Alzheimer’s disease and other dementias
are high users of long-term care services. Wimo and
colleagues (2010) used cost-of-illness studies from different
countries to estimate the direct costs of dementia, including only the resources used to care for people with dementia. In 2009, the direct costs of dementia were estimated at
0.5% of GDP on average among EU member states.
44
As the number of older persons suffering from dementia
is already large, and is expected to grow in the future,
dementia has become a health policy priority in many countries. National policies typically involve measures to improve
early diagnosis, promote quality of care for people with
dementia, and support informal caregivers (Wortmann, 2009;
Juva, 2009; Ersek et al., 2009; Kenigsberg, 2009).
In January 2011, the European Parliament adopted a
resolution calling for dementia to be made an EU health
priority and urging member states to develop dedicated
national plans and strategies (only a small number of
countries including France and the United Kingdom, along
with Norway, currently have national strategies in place).
These strategies should address the social and health
consequences, as well as services and support for sufferers
and their families.
A Joint Action between European member states aims
to improve knowledge on dementia and its consequences
and to promote the exchange of information to preserve
health, quality of life, autonomy and dignity of people
living with dementia and their carers (ALCOVE, 2012).
Dementia prevalence rates are based on estimates
of the total number of persons aged 60 years and over
living with dementia divided by the size of the corresponding population. Estimates by Wimo et al. (2010)
are based on previous national epidemiological
studies and meta-analyses.
Given the divergence in scale and accuracy of the
sources used across countries, the estimates should
be used with caution.
1.15. DEMENTIA PREVALENCE
1.15.1. Prevalence of dementia, population aged 60 years and over, 2009
%
7
6.6
6.5
6.3
6.3
6.2
6.4
6.1
6
6.0
5.9
5.7
5.7
5.6
5.6
5.6
5.5
5.5
5.5
5.4
5
5.4
6.4
5.6
5.3
5.3
5.2
5.0
5.0
5.5
5.1
4.9
4.8
4.8
4.7
4.4
4.4
4.2
4
3.2
3
2
1
Fr
an
ce
It a
l
Sp y
Un
ai
S
i te w n
d ed
K i en
ng
d
B e om
lg
iu
Au m
st
Ge r ia
rm
a
C y ny
pr
Po us
rt
De uga
L u nm l
xe a
m rk
bo
u
Fi rg
nl
an
Ne E d
th U2
er 7
la
n
Ir e d s
la
Sl nd
ov
en
Es ia
to
n
Po i a
Li lan
th d
ua
ni
La a
Hu t v i a
ng
Sl
ov G ar y
ak re
Re e c e
pu
C z B blic
e c ul g
h
Re ar i a
pu
Ro b l i c
m
an
ia
M
al
ta
Sw
it z
er
la
No nd
rw
a
Se y
rb
Ic i a
el
an
d
F Y M Cr o
R on t a t i
of en a
M eg
ac ro
ed
on
Tu ia
rk
ey
0
Source: Wimo et al. (2010).
1 2 http://dx.doi.org/10.1787/888932703658
1.15.2. Age- and sex-specific prevalence of dementia in EU member states, 2009
Male
Female
Prevalence (%)
60
50
40
30
20
10
0
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95 and over
Age group
Source: Alzheimer Europe (2009).
1 2 http://dx.doi.org/10.1787/888932703677
45
1.16. ASTHMA AND COPD PREVALENCE
Asthma is a disease of the bronchial tubes characterised by “wheezing” during breathing, shortness of breath or
coughing. Asthma is the single most common chronic
disease among children, and also affects many adults. It is
a significant public health problem and a high-burden
disease for which prevention is partly possible and treatment can be effective. Its causes are not well understood,
but effective medicines are available to help in maintaining
quality of life and avoiding disability and death (The Union/
ISAAC, 2011).
Chronic obstructive pulmonary disease (COPD) – the
term now used to describe chronic bronchitis and emphysema – is another high-burden disease causing disability
and impairing quality of life, as well as generating high
costs. COPD is characterised by difficult breathing that is
not fully reversible and usually progressive. Patients are
often smokers or ex-smokers, and their symptoms rarely
develop before age 40. COPD is among the leading causes of
chronic morbidity and mortality in the EU. Approximately
200 000 to 300 000 people die each year in Europe because
of COPD, and among respiratory diseases, it is the leading
cause of lost work days (European Lung Foundation, 2012).
COPD is preventable and treatable. Proper management of
both asthma and COPD in primary care settings can reduce
exacerbation and costly hospitalisation (see Indicator 4.1
“Avoidable admissions: Respiratory diseases”).
In response to a health survey question asking whether
adults aged 15 years and over had asthma during the last
12 months, prevalence ranged from 1.6% in Romania, to
7.0% in France (Figure 1.16.1). Rates also exceeded 5% in
Germany, Hungary and Malta, and were less than 3% in
Bulgaria, Estonia, Latvia, Romania and the Slovak Republic.
Among 17 EU member states the average prevalence rate
was 3.8%. Asthma was more commonly reported by females
(4.3% vs. 3.3% for males). Slovenia is an exception, with a
slightly higher male prevalence. The largest female-male
disparity was in Turkey (5% vs. 2.5%), whereas no disparity
existed in Cyprus (both 3.9%).
The reported prevalence of COPD among adults aged
15 years and over ranged from 1.2% in Malta, to 4.7% in
Hungary, and 6.2% in Turkey (Figure 1.16.2). Among
16 EU member states, average prevalence was 3.1%, with
slightly higher prevalence among females (3.5% vs. 2.9%). In
Cyprus, France, Romania and Spain, however, prevalence
was higher among males. The prevalence of COPD also
increases with age.
Persons with low levels of education are more than
twice as likely to report COPD than those with high levels
46
(Figure 1.16.3). Large disparities in COPD rates between
persons with higher and lower levels of education are
evident in Belgium, Romania, Spain and Estonia. Persons
from low socio-economic groups also report higher rates of
smoking, which is the major risk factor for COPD.
The lower reported asthma and COPD prevalence
among new EU member states in all likelihood reflects
underdiagnosis and undertreatment, although rates in
these countries have increased sharply in recent years,
possibly reflecting greater awareness of this condition
along with changes in diagnostic practice (Braman, 2006;
The Union/ISAAC, 2011).
A number of EU actions reflect an increased focus on
asthma and COPD. These include the Council Conclusions
on prevention, early diagnosis and treatment of chronic
respiratory diseases in children (12/2011), and the Commission Reflection Paper on Chronic Diseases (03/2012). Both
aim to identify issues, gaps and suggestions for action to
improve current policies and activities on chronic diseases
such as asthma and COPD.
Estimates of the prevalence of asthma and chronic
obstructive pulmonary disease (COPD) are derived
from European Health Interview Survey questions,
conducted in many EU member states between 2006
and 2010. Typically, respondents were asked: “Do you
have or have you ever had any of the following
diseases or conditions? 1) Asthma (allergic asthma
included) (yes/no). 2) Chronic bronchitis, chronic
obstructive pulmonary disease, emphysema (yes/no).
If yes: Was this disease/condition diagnosed by a
medical doctor? (yes/no). Have you had this disease/
condition in the past 12 months? (yes/no).”
The same survey also asked for information on age,
sex and educational level. Data rely on self-report,
and are subject to errors in recall. Data are not
age-standardised, with aggregate country estimates
representing crude rates among respondents aged
15 years and over. The data, therefore, exclude the
prevalence of childhood asthma (age 0-14 years).
1.16. ASTHMA AND COPD PREVALENCE
1.16.1. Self-reported asthma, 2008 (or nearest year)
France
1.16.2. Self-reported COPD, 2008 (or nearest year)
Hungary
7.0
Germany
5.3
France
Hungary
5.3
Belgium
Malta
5.2
Austria
4.3
Spain
4.3
Belgium
4.3
4.0
Austria
3.7
Spain
3.5
Bulgaria
3.3
Latvia
3.3
Slovak Republic
3.3
4.2
Czech Republic
4.7
4.0
Cyprus
3.9
EU17
3.8
Greece
3.6
Poland
3.6
Slovenia
3.1
EU16
3.1
Poland
3.0
Greece
Slovenia
2.9
3.5
Slovak Republic
Czech Republic
2.7
Estonia
2.3
Latvia
2.3
Bulgaria
Cyprus
2.1
Romania
1.7
Malta
1.6
Turkey
2
1.2
Turkey
3.8
0
2.4
Estonia
2.0
Romania
2.7
4
6.2
6
8
10
0
2
4
6
8
10
1 2 http://dx.doi.org/10.1787/888932703696
1 2 http://dx.doi.org/10.1787/888932703715
1.16.3. Self-reported COPD by highest attained level of education, 2008 (or nearest year)
Low
Medium
High
10
4.4
4.3
1.8
1.0
0.6
0.7
0.8
1.5
2.0
2.1
2.4
2.6
2.8
2.8
2.9
3.9
1.5
1.4
1.5
1.6
1.9
1.8
1.9
2.5
2.9
2.7
4.3
4.5
4.5
2.1
2.6
3.2
2.8
4.7
4.8
1.9
1.8
1.5
1.4
2
2.9
3.1
2.7
2.3
3.2
3.3
4
3.5
3.8
5.0
6
4.7
5.7
6.3
6.6
7.0
7.4
8
y
ke
ta
al
M
Tu
r
Ro
m
an
ia
a
ni
to
pu
Cz
ec
h
Re
Cy
Es
ic
bl
us
pr
ia
Sl
ov
en
ia
16
tv
La
pu
Re
ak
ov
Sl
EU
ic
bl
nd
la
Po
ce
ee
ar
lg
Bu
Gr
ia
n
ai
Sp
ria
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Au
ce
Fr
an
m
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lg
Be
Hu
ng
ar
y
0
1 2 http://dx.doi.org/10.1787/888932703734
47
© OECD 2012
Chapter 2
Determinants of health
2.1. Smoking and alcohol consumption among children . . . . . . . . . . . . . . .
50
2.2. Overweight and obesity among children . . . . . . . . . . . . . . . . . . . . . . . . .
52
2.3. Fruit and vegetable consumption among children. . . . . . . . . . . . . . . . .
54
2.4. Physical activity among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
56
2.5. Smoking among adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58
2.6. Alcohol consumption among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . .
60
2.7. Overweight and obesity among adults. . . . . . . . . . . . . . . . . . . . . . . . . . .
62
2.8. Fruit and vegetable consumption among adults . . . . . . . . . . . . . . . . . .
64
49
2.1. SMOKING AND ALCOHOL CONSUMPTION AMONG CHILDREN
Regular smoking or excessive drinking in adolescence
has both immediate and long-term health consequences.
Children who establish smoking habits in early adolescence increase their risk of cardiovascular diseases, respiratory illnesses and cancer. They are also more likely to
experiment with alcohol and other drugs. Alcohol misuse
is itself associated with a range of social, physical and
mental health problems, including depressive and anxiety
disorders, obesity and accidental injury (Currie et al., 2012).
Results from the Health Behaviour in School-aged
Children (HBSC) surveys, a series of collaborative crossnational studies conducted in most EU member states,
allow for monitoring of smoking and drinking behaviours
among adolescents. Across all EU member states who
responded to the survey, the proportions of 15-year-old
boys and girls who smoke are similar, but more boys get
drunk.
Boys and girls in Austria, Croatia, the Czech Republic,
Hungary, Latvia and Lithuania smoke most, with more
than 25% reporting that they smoke at least once a week
(Figure 2.1.1). In contrast, less than 15% of 15-year-olds in
Nordic countries (Denmark, Iceland, Norway and Sweden),
Ireland, Poland, Portugal and the United Kingdom smoke
weekly. A number of countries report higher rates of
smoking for girls, although only in the Czech Republic and
Spain is the difference in excess of 5%. Smoking is more
prevalent among boys in Latvia, Lithuania and Romania,
where the difference is 10% or greater.
Drunkenness at least twice in their lifetime is reported
by more than 40% of 15-year-olds in the Czech Republic,
Denmark, Estonia, Finland, Hungary, Latvia, Lithuania,
Slovenia and the United Kingdom (Figure 2.1.2). Much lower
rates (less than 20%) are reported in Italy, Luxembourg and
the Netherlands, as well as Iceland and the Former Yugoslav
Republic of Macedonia. Across all surveyed EU member
states, boys are more likely than girls to report repeated
drunkenness (36% vs. 31%). Croatia, Hungary, Lithuania and
Romania have the biggest differences, with rates of alcohol
abuse among boys at least 10% higher than those of girls. In
four countries, Finland, Spain, Sweden and the United
Kingdom, around 5% more girls than boys report repeated
drunkenness.
Recent smoking and drinking rates for 15-year-old
boys and girls are compared in Figure 2.1.3. Countries
50
above the 45 degree line have higher rates for boys, and
countries below the line higher rates for girls. Countries
with higher rates of smoking among boys also tend to
report higher rates for girls, with the same finding for
drinking rates.
Rates of smoking and drunkenness are also available
for 13-year-olds (Currie et al., 2012). At this age, around 5% of
children surveyed across the entire European Union smoke
weekly, and in the Czech Republic, Estonia, Latvia, Romania
and the Slovak Republic, the figure is higher at 8% or more.
Over one in ten children in a range of countries including
Croatia, the Czech Republic, Greece, Italy, Romania, the
Slovak Republic and the United Kingdom have experienced
drunkenness at least twice. In Croatia, the Czech Republic,
Greece, Italy and Romania, high rates of repeated drunkenness at 13 are seen for boys.
Risk-taking behaviours among adolescents are falling,
with regular smoking for both boys and girls and drunkenness rates for boys showing some decline from the levels of
the late 1990s (Figure 2.1.4). Levels of smoking for both
sexes are at their lowest for a decade with, on average,
fewer than one in five children of either sex smoking regularly. However, increasing rates of smoking and drunkenness among adolescents in Estonia, Hungary, Latvia,
Lithuania and Poland are cause for concern.
Estimates for smoking refer to the proportion of
15-year-old children who self-report smoking at least
once a week. Estimates for drunkenness record the
proportions of 15-year-old children saying they have
been drunk twice or more in their lives.
Data for 24 European Union member states and five
other countries are from the Health Behaviour in
School-aged Children (HBSC) surveys undertaken
between 1993-94 and 2009-10. Data are drawn from
school-based samples of 1 500 in each age group (11-,
13- and 15-year-olds) in most countries. Turkey was
included in the 2009-10 HBSC survey, but children
were not questioned on drinking and smoking.
2.1. SMOKING AND ALCOHOL CONSUMPTION AMONG CHILDREN
2.1.1. Smoking among 15-year-olds, 2009-10
2.1.2. Drunkenness among 15-year-olds, 2009-10
Smoking at least once a week
Drunk at least twice in life
Boys
Austria
Czech Republic
Hungary
Italy
Spain
Latvia
Lithuania
France
Finland
Luxembourg
Slovenia
EU24
Belgium
Netherlands
Slovak Republic
Estonia
Germany
Romania
Sweden
United Kingdom
Ireland
Denmark
Greece
Poland
Portugal
Boys
Girls
29
25
22
23
22
23
15
28
26
26
22
32
21
20
20
19
20
19
Denmark
Lithuania
Finland
United Kingdom
Estonia
Latvia
Czech Republic
Slovenia
Spain
Hungary
Austria
Slovak Republic
EU24
Ireland
Germany
Poland
Sweden
Belgium
Greece
Portugal
Romania
France
Luxembourg
Netherlands
Italy
34
22
19
20
18
19
17
16
17
15
17
21
16
22
15
15
15
25
15
13
14
10
12
14
13
14
13
18
12
10
16
11
25
Croatia
Switzerland
FYR of Macedonia
Norway
Iceland
15
9
8
7
0
14
9
9
10
20
30
Source: Currie et al. (2012).
2.1.3. Risk behaviours of 15-year-olds by sex,
2009-10
Regular cigarette smoking
36
48
28
30
27
27
21
23
19
18
45
35
47
39
31
31
51
46
36
31
39
36
35
35
27
29
26
23
18
17
47
26
17
20
17
19
14
19
28
26
26
20
44
27
16
18
8
19
20
40
60
80
%
1 2 http://dx.doi.org/10.1787/888932703772
2.1.4. Trends in repeated drunkenness and regular
smoking among 15-year-olds, 14 EU countries
Boys
43
40
DNK
ROU
HUN
HRV
DEU
POL
IRL
36
40
36
32
27
EST
CZE
20
GBR
FIN
1993-94
1997-98
%
LVA
SVK GRC
BEL
EST
FRA
NOR
LUX
ROU
CHE
PRT
AUT
NLD
HUN
LUX
CHE
CZE
MKD ITA
ITA
FRA
SWE
GRC
FIN,SVN
ISL
BEL
DNK POL
ESP
MKD
NLD
IRL SWE DEU
ISL PRT
GBR
NOR
42
10
SVK
AUT
HRV
LTU
SVN
37
30
LVA
45
38
LTU
55
Girls
Repeated drunkenness
50
65
15
40
Repeated drunkenness
Boys aged 15 (%)
35
42
42
%
45
44
1 2 http://dx.doi.org/10.1787/888932703753
25
39
31
57
44
37
0
40
%
56
55
47
Norway
Croatia
Switzerland
Iceland
FYR of Macedonia
27
19
Girls
ESP
2001-02
2005-06
2009-10
20
20
19
19
2005-06
2009-10
Regular smoking
50
40
30
27
26
25
25
23
20
19
10
5
5
15
25
35
45
55
65
Girls aged 15 (%)
1 2 http://dx.doi.org/10.1787/888932703791
1993-94
1997-98
2001-02
Source: Currie et al. (2000); Currie et al. (2004); Currie et al. (2008); Currie
et al. (2012); WHO (1996).
1 2 http://dx.doi.org/10.1787/888932703810
51
2.2. OVERWEIGHT AND OBESITY AMONG CHILDREN
Children who are overweight or obese are at greater risk
of poor health in adolescence and also in adulthood. Among
young people, orthopaedic problems and psychosocial
problems such as low self-image, depression and impaired
quality of life can result from overweight. Excess weight
problems in childhood are associated with an increased risk
of being an obese adult, at which point cardiovascular
disease, diabetes, certain forms of cancer, osteoarthritis, a
reduced quality of life and premature death become health
concerns (Sassi, 2010; Currie et al., 2012).
Evidence suggests that even if excess childhood
weight is lost, adults who were obese children retain an
increased risk of cardiovascular problems. And although
dieting can combat obesity, children who diet are at a
greater risk of putting on weight following periods of
dieting. Eating disorders, symptoms of stress and postponed physical development can also be products of
dieting (WHO Europe, 2009).
Among 15-year-olds in EU member states, boys tend to
report excess weight more often than girls; one-in-six boys
and one-in-ten girls reported being overweight or obese
in 2009-10 (Figure 2.2.1). More than 15% of adolescents in
southern European countries (Greece, Italy, Portugal and
Spain), as well as in Croatia, Iceland, Luxembourg and
Slovenia report being overweight or obese. Fewer than 10%
of children in Latvia and Lithuania, as well as in Denmark,
France and the Netherlands report overweight or obesity.
Boys’ and girls’ perceptions of having weight problems
often differ from their reported weight. Among 15-year-olds,
40% of girls and 22% of boys across EU member states
thought they were too fat. Further, there is also no clear
association between weight problems and weight reduction
behaviours, with 22% of girls and 9% of boys reporting that
they engage in weight-reduction behaviour; twice the rate of
girls who report being overweight or obese, but only half that
of boys.
Young people who report being overweight are more
likely to miss eating breakfast, are less physically active, and
spend more time watching television (Currie et al., 2012).
Reported rates of excess weight have increased
slightly over the past decade in most EU member states
(Figure 2.2.2). Average reported rates of overweight and
52
ob esity acro ss the EU increased b etwe en 20 01-02
and 2009-10 from 11% to 13% of 15-year-olds. The largest
increases during the eight year period were found in the
Czech Republic, Estonia, Poland, Romania and Slovenia, all
greater than 5%. Only Denmark and the United Kingdom
report any significant reductions in the proportion of overweight or obese at age 15 between 2001-02 and 2009-10,
although non-response rates to questions about selfreported height and weight require cautious interpretation.
Childhood is an important period for forming healthy
behaviours, and the increased focus on obesity at both
national and international levels has stimulated the
implementation of many community-based initiatives in
European countries in recent years. Studies show that
locally focused interventions, targeting children to 12 years
of age can be effective in changing behaviours. Schools
provide an opportunity to ensure that children understand
the importance of good nutrition and physical activity, and
can benefit from both. Teachers and health professionals are
often involved as providers of health and nutrition activities,
and the most frequent community-based initiatives target
professional training, the social or physical environment
and actions for parents (Bemelmans et al., 2011).
Estimates of overweight and obesity are based on
body mass index (BMI) calculations using child selfreported height and weight. Overweight and obese
children are those whose BMI is above a set of ageand sex-specific cut-off points (Cole et al., 2000).
Self-reported height and weight is subject to underreporting, missing data and error, and requires
cautious interpretation.
Data for 24 EU member states and six other countries are from the Health Behaviour in School-aged
Children (HBSC) surveys undertaken between 2001-02
and 2009-10. Data are drawn from school-based
samples of 1 500 in each age group (11-, 13- and
15-year-olds) in most countries.
2.2. OVERWEIGHT AND OBESITY AMONG CHILDREN
2.2.1. Reported overweight (including obesity) among 15-year-olds, 2009-10
Girls
Boys
Portugal
Greece
Slovenia
Ireland
Luxembourg
Spain
United Kingdom
Austria
Finland
Hungary
Italy
Czech Republic
Germany
Poland
EU24
Estonia
Belgium
Denmark
Romania
France
Latvia
Slovak Republic
Sweden
Lithuania
Netherlands
15
13
13
12
12
12
11
11
11
11
11
10
10
10
10
9
9
8
8
7
7
7
7
5
5
11
10
7
6
6
20
28
23
16
22
19
12
19
17
19
22
19
18
17
17
16
15
10
20
13
13
15
17
13
11
Iceland
Norway
Croatia
Switzerland
FYR of Macedonia
Turkey
13
30
% of 15-year-olds
19
10
20
17
23
14
21
17
0
0
10
20
30
% of 15-year-olds
Source: Currie et al. (2012), based on HBSC survey.
1 2 http://dx.doi.org/10.1787/888932703829
2.2.2. Change in reported overweight among 15-year-olds, 2001-02, 2005-06 and 2009-10
2001-02
2005-06
2009-10
21
% of 15-year-olds
25
18
14
13
14
17
17
12
12
12
10
11
11
10
9
9
6
6
6
7
7
7
8
8
8
9
15
17
18
16
18
17
15
13
12
13
14
12
11
12
17
17
17
15
16
15
16
15
14
15
14
14
14
14
14
14
11
11
12
13
13
12
12
12
11
12
11
11
12
12
10
9
9
9
10
10
10
11
11
12
11
13
15
14
13
15
16
20
4
5
FY
R
Sw
it z
er
la
nd
T
ur
of
ke
M
y
ac
ed
on
i
No a
rw
ay
Cr
oa
tia
Ic
el
an
d
ce
ee
Gr
ov
en
ia
l
Sl
Po
r tu
ga
g
ly
ur
It a
bo
m
xe
Lu
n
ai
Sp
y
ng
ar
ria
st
Hu
ic
pu
Au
bl
ia
an
Cz
ec
h
Re
m
nd
Ir e
Ro
la
y
an
rm
d
an
Ge
nl
nd
la
Po
Fi
24
EU
a
en
ni
to
Es
m
ed
do
ng
Ki
i te
d
Sw
lg
iu
m
ic
Be
Un
pu
bl
ia
Sl
ov
ak
Re
tv
La
ce
a
ni
Fr
an
k
ua
th
ar
Li
la
nm
er
th
Ne
De
nd
s
0
Source: Currie et al. (2004); Currie et al. (2008); Currie et al. (2012), based on HBSC surveys.
1 2 http://dx.doi.org/10.1787/888932703848
53
2.3. FRUIT AND VEGETABLE CONSUMPTION AMONG CHILDREN
Nutrition is important for children’s development and
long-term health. Eating fruit during adolescence, for
example, in place of high-fat, sugar and salt products, can
protect against health problems such as obesity, diabetes,
and heart problems. Moreover, eating fruit and vegetables
when young can be habit forming, promoting healthy
eating behaviours for later life.
A number of factors influence the amount of fruit
consumed by adolescents, including family income, the
cost of alternatives, preparation time, whether parents eat
fruit, and the availability of fresh fruit which can be linked
to the country or local climate (Rasmussen et al., 2006).
Fruit and vegetable consumption have a high priority as
indicators of healthy eating in most European countries.
In European countries in 2009-10, only around onethird of girls and one-quarter of boys aged 15 years ate at
least one piece of fruit daily, according to the latest Health
Behaviour in School-aged Children (HBSC) survey (Currie
et al., 2012). Overall, boys in Denmark, Portugal and Italy, and
girls in Denmark, Norway, the Former Yugoslav Republic of
Macedonia and Switzerland had the highest rates of daily
fruit consumption. Fruit consumption was relatively low in
Estonia, Latvia, Lithuania and Poland, and in contrast to
other Nordic countries, Finland and Sweden, with rates of
around one-in-four among girls and one-in-five for boys
(Figure 2.3.1).
In all countries, girls were more likely to eat fruit daily.
The gap between the fruit consumption of boys and girls is
largest at age 15 for most countries, with the greatest disparities found in Denmark, Finland, Germany and Norway.
Daily vegetable eating was also reported by around
one-third of girls and quarter of boys on average across
EU member states in 2009-10 (Figure 2.3.2). Girls in Belgium
most commonly ate vegetables daily (60%), followed by
Denmark, France and Switzerland (45-50%). Belgium also
led the way for boys (46%), with close to 40% in France and
Ireland. Eating vegetables daily was less common in
Austria, Estonia and Spain, as well as in Croatia (girls), and
Finland and Latvia (boys).
Similar to fruit eating, in all countries a higher proportion of girls ate vegetables daily. The disparity was especially large in Finland, where 35% of girls, but only 14% of
54
boys reported eating vegetables each day. Denmark and
Germany also had large differences, although rates were
comparatively high for both boys and girls in Denmark.
In most countries, it was more common for 15-year-olds
to report eating fruit daily, rather than vegetables
(Figure 2.3.3). However, in a number of western European
countries, including Belgium, the Netherlands, Sweden,
Ireland and France, daily vegetable eating was more common.
Average reported rates of daily vegetable consumption
a c ro s s E U m e m b e r s t a t e s s h owe d s o m e i n c re a s e
between 2001-02 and 2009-10, for both girls and boys
(Figure 2.3.3). Fruit consumption however was less clear,
with a small increase among girls, while the rates for boys
have remained largely unchanged.
Effective and targeted strategies are required to ensure
that children are eating enough fruit and vegetables to
conform with recommended national dietary guidelines. A
study of European school children found that they generally hold a positive attitude toward fruit intake, and report
good availability of fruit at home, but lower availability at
school and during leisure time. Increased accessibility to
fruit and vegetables, combined with educational and
motivational activities can help in increasing both fruit and
vegetable consumption (Sandvik et al., 2005).
Dietary habits are measured here in terms of the
proportions of children who report eating fruit and
vegetables at least every day or more than once a day.
In addition to fruit and vegetables, healthy nutrition
also involves other types of foods.
Children (HBSC) surveys undertaken between 2001-02
and 2009-10. Data are drawn from school-based
samples of 1 500 in each age group (11-, 13- and
15-year-olds) in most countries.
2.3. FRUIT AND VEGETABLE CONSUMPTION AMONG CHILDREN
2.3.1. Daily fruit eating among 15-year-olds,
2009-10
Boys
Denmark
Belgium
Czech Republic
Germany
Luxembourg
Romania
Italy
Portugal
United Kingdom
France
Slovenia
Austria
Ireland
Spain
EU24
Slovak Republic
Netherlands
Finland
Lithuania
Greece
Estonia
Hungary
Latvia
Sweden
Poland
2.3.2. Daily vegetable eating among 15-year-olds,
2009-10
Girls
Boys
56
34
40
30
40
29
40
23
40
32
40
29
39
33
39
34
39
32
38
31
38
25
37
23
35
28
31
35
35
26
31
27
30
20
29
15
29
18
28
26
27
17
27
25
26
16
26
22
25
20
Norway
FYR of Macedonia
Switzerland
Turkey
Iceland
Croatia
49
29
41
30
37
23
35
23
24
10
20
29
30
40
50
60
%
Girls
60
46
49
33
47
38
39
42
42
35
40
34
39
30
36
21
35
14
33
24
33
17
33
25
32
24
32
21
30
21
28
20
28
19
26
20
26
17
25
16
25
20
24
15
23
12
22
20
21
16
Switzerland
FYR of Macedonia
Norway
Turkey
Iceland
Croatia
44
29
Belgium
Denmark
France
Ireland
Netherlands
United Kingdom
Sweden
Czech Republic
Finland
EU24
Germany
Greece
Luxembourg
Romania
Poland
Lithuania
Portugal
Italy
Slovenia
Latvia
Slovak Republic
Spain
Austria
Hungary
Estonia
45
34
38
27
33
23
31
21
27
19
19
10
20
23
30
40
50
60
%
1 2 http://dx.doi.org/10.1787/888932703867
2.3.3. Daily fruit and vegetable eating among
15-year-olds, 2009-10
1 2 http://dx.doi.org/10.1787/888932703886
2.3.4. Trends in daily fruit and vegetable eating among
15-year-olds, 21 EU countries, 2001-02 to 2009-10
2001-02
%
40
Daily vegetable eating (%)
60
2005-06
2009-10
Fruits
BEL
Vegetables
50
35
34 34
FRA
IRL
40
NLD
CHE
30
20
29
MKD
LUX
NOR
CZE
POL
ROU
TUR
FIN
DEU
PRT
LTU
SVN ITA
HUN
HRV
LVA
ESP
EST
AUT ISL, SVK
30
32
DNK
GBR
SWE
GRC
34
33
25
25
25
24
24
24
23
20
10
10
20
30
40
50
60
Daily fruit eating (%)
1 2 http://dx.doi.org/10.1787/888932703905
Girls
Boys
Girls
Boys
Source: Currie et al. (2004); Currie et al. (2008); Currie et al. (2012).
1 2 http://dx.doi.org/10.1787/888932703924
55
2.4. PHYSICAL ACTIVITY AMONG CHILDREN
Undertaking physical activity in adolescence is beneficial for health, and can set standards for adult physical
activity levels, thereby influencing health outcomes in later
life. Research supports the role that physical activity has in
child and adolescent development, learning and wellbeing, and in the prevention and treatment of a range of
youth health issues including asthma, mental health, bone
health and obesity. More direct links to adult health are
found between physical activity in adolescence and its
effect on overweight and obesity and related diseases,
breast cancer rates and bone health in later life. The health
effects of adolescent physical activity are sometimes
dependent on the activity type, e.g. water physical activities
in adolescence are effective in the treatment of asthma,
and exercise is recommended in the treatment of cystic
fibrosis (Hallal et al., 2006; Currie et al., 2012).
One extensive study recommends that children participate in at least 60 minutes of moderate-to-vigorous physical
activity daily, although evidence suggests that many
children do not meet these guidelines (Strong et al., 2005;
Borraccino et al., 2009; Hallal et al., 2012). Some of the factors
influencing the levels of physical activity undertaken by
adolescents include the availability of space and equipment,
the child’s present health conditions, their school curricula
and other competing pastimes.
Only one-in-five children in EU member states report
that they undertake moderate-to-vigorous exercise regularly, according to results from the 2009-10 HBSC survey
(Figure 2.4.1). At age 11, Austria, Ireland and Spain stand
out as strong performers with over 30% of children reporting exercising for at least 60 minutes per day over the past
week. At age 15, children in Ireland maintain their place,
along with the Czech and Slovak Republics, at 20%. Country
rankings vary according to the child’s age. Children in
Denmark, France and Italy were least likely to report exercising regularly. Italy appears at the lower end for both boys
and girls, and at both ages. A higher proportion of boys
consistently reported undertaking physical activity,
whether moderate or vigorous, across all countries and all
age groups (Figures 2.4.2 and 2.4.3).
It is of concern that physical activity tends to fall
between ages 11 to 15 for most European countries, with
56
boys in Italy the only exception, although they have the
lowest rate of physical activity at age 15. In Austria,
Finland, Norway and Spain, the rates of exercising among
boys halve between ages 11 and 15. The rates of girls exercising to recommended levels also fall between the ages
of 11 and 15 years. In many countries, rates for 15-year-old
girls are less than half of those at age 11, and in Austria,
Ireland, Romania and Spain, rates of physical activity
among girls fall by over 60%.
The change in activity levels between 11- and
15-year-olds may reflect a move to different types of
activity, since free play is more common among younger
children, and structured activities at school or in sports
clubs among older groups. Boys tend to be more physically
active than girls in all countries, also suggesting that the
opportunities to undertake physical activity may be
gender-biased (Currie et al., 2012).
Daily moderate-to-vigorous physical activity for 2005-06
and 2009-10 averaged across 21 EU member states are shown
in Figure 2.4.3. Reported levels fell slightly for both boys and
girls, and in all age groups, except boys aged 15 years.
Data for physical activity considers the regularity of
moderate-to-vigorous physical activity as reported
by 11-, 13- and 15-year-olds for the years 2005-06
and 2009-10. Moderate-to-vigorous physical activity
refers to exercise undertaken for at least an hour each
day which increases the heart rate, and leaves the
child out of breath sometimes.
Children (HBSC) surveys. Data are drawn from schoolbased samples of 1 500 in each age group in most
countries.
2.4. PHYSICAL ACTIVITY AMONG CHILDREN
2.4.1. Daily moderate-to-vigorous physical activity, 11- and 15-year-olds, 2009-10
Girls aged 11
Girls aged 15
Boys aged 11
Boys aged 15
Girls
Boys
12
31
8
26
10
25
14
23
10
23
9
22
12
22
9
20
7
20
10
20
12
20
10
19
13
19
18
13
18
13
11
17
9
17
10
17
9
16
6
14
5
12
8
10
5
9
5
7
8
19
9
19
9
17
9
17
6
11
40
30
20
10
40
20
28
43
41
25
38
17
28
25
31
23
30
21
30
27
25
13
32
16
31
20
32
24
28
19
24
19
26
22
32
24
23
18
19
13
28
16
19
13
23
14
21
18
14
16
21
14
10
12
FYR of Macedonia
Croatia
Turkey
Iceland
Norway
Switzerland
13
28
50
%
Austria
Ireland
Spain
Finland
Czech Republic
Poland
Hungary
Slovak Republic
Germany
Romania
Slovenia
United Kingdom
EU24
Netherlands
Latvia
Luxembourg
Lithuania
Sweden
Belgium
Estonia
Portugal
Greece
Denmark
France
Italy
9
39
0
32
22
31
22
27
18
25
15
27
12
20
12
0
10
20
30
40
50
%
1 2 http://dx.doi.org/10.1787/888932703943
2.4.2. Vigorous physical activity for two
or more hours per week, 15-year-olds, 2009-10
2.4.3. Trends in daily moderate-to-vigorous physical
activity, 21 EU countries, 2005-06 to 2009-10
Girls (%)
80
2005-06
%
40
DNK
2009-10
Girls
Boys
NOR
60
40
ROU
20
DEU LUX
ISL
FIN BEL
CHE
SWE
GBR
GRC
EST LVA
AUT
IRL
SVK
FRA
SVN
ITA
ESP
HUN
POL
CZE
PRT
LTU
MKD HRV
30
29
27
24
23
21
20
19
19
14
19
13
11
9
10
TUR
0
0
0
20
40
60
80
Boys (%)
1 2 http://dx.doi.org/10.1787/888932703962
Age 11
Age 13
Age 15
Age 11
Age 13
Age 15
Source: Currie et al. (2008); Currie et al. (2012).
1 2 http://dx.doi.org/10.1787/888932703981
57
2.5. SMOKING AMONG ADULTS
Tobacco is responsible for about one-in-ten adult
deaths worldwide, equating to about 5 million deaths each
year (WHO, 2012a). It is a major risk factor for at least two
of the leading causes of premature mortality – circulatory
disease and cancer, increasing the risk of heart attack,
stroke, lung cancer, cancers of the larynx and mouth, and
pancreatic cancer. Smoking also causes peripheral vascular
disease and hypertension. In addition, it is an important
contributory factor for respiratory diseases such as chronic
obstructive pulmonary disease (COPD), while smoking
among pregnant women can lead to low birth weight and
illnesses among infants. It remains the largest avoidable
risk to health in European countries.
The proportion of daily smokers among the adult
population varies greatly across countries (Figure 2.5.1).
Only seven of 27 EU member states had rates of less than
20% of the adult population smoking daily in 2010. Rates
were lowest in Finland, Malta, Luxembourg, Portugal,
Slovenia, the Slovak Republic and Sweden, as well as
Iceland and Norway. Although large disparities remain,
smoking rates across most EU member states have
declined. On average, smoking rates have decreased by
about 5 percentage points since 2000, with a higher decline
among men than women. Large declines occurred in
Denmark (31% to 20%), Latvia (42% to 28%), Luxembourg
(26% to 18%), and the Netherlands (29% to 21%), as well as
in Norway and Iceland. Greece maintained the highest level
of smoking around 2010, along with Bulgaria and Ireland,
with close to 30% or more of the adult population smoking
daily. The Czech Republic is one of the few EU member
states where smoking rates appear to be increasing.
In the post-war period, most European countries
tended to follow a general pattern marked by very high
smoking rates among men (50% or more) through to
the 1960s and 1970s, while the 1980s and the 1990s were
characterised by a downturn in tobacco consumption.
Much of this decline can be attributed to policies aimed at
reducing tobacco consumption through public awareness
campaigns, advertising bans and increased taxation, in
response to rising rates of tobacco-related diseases (EC,
2012c). In addition to government policies, actions by anti-
58
smoking interest groups were very effective in reducing
smoking rates by changing beliefs about the health effects
of smoking.
Smoking prevalence among men is higher in all
EU member states except in Sweden (Figure 2.5.2). In other
Nordic countries (Denmark, Iceland, Norway), as well as in
the United Kingdom, male and female smoking rates are
close to equal. In 2010, the gender gap in smoking rates was
particularly large in Latvia and Lithuania, as well as in
Cyprus, Bulgaria, Romania and Turkey. Female smoking
rates continue to decline in most countries, and in several
at a faster pace than male rates. However, female smoking
rates have shown little or no decline since 2000 in three
countries: the Czech Republic, France and Italy.
Several studies provide strong evidence of socioeconomic differences in smoking and mortality (Mackenbach
et al., 2008). People in lower social groups have a greater
prevalence and intensity of smoking, a higher all-cause
mortality rate and lower rates of cancer survival (Woods et al.,
2006). The influence of smoking as a determinant of overall
health inequalities is such that, if the entire population did
not smoke, mortality differences between social groups
would be halved (Jha et al., 2006).
The proportion of daily smokers is defined as the
percentage of the population aged 15 years and over
who report smoking every day.
International comparability is limited due to the
lack of standardisation in the measurement of
smoking habits in health interview surveys across
EU member states. Variations remain in the age
groups surveyed, wording of questions, response
categories and survey methodologies, e.g. in a number
of countries, respondents are asked if they smoke
regularly, rather than daily.
2.5. SMOKING AMONG ADULTS
2.5.1. Adult population smoking daily, 2010 and change in smoking rates, 2000-10 (or nearest year)
Change 2000-10
Sweden
Luxembourg
Portugal
Slovenia
Finland
Malta
Slovak Republic
Denmark
Belgium
Romania
Netherlands
United Kingdom
Germany
EU27
Italy
Austria
France
Poland
Czech Republic
Cyprus
Estonia
Spain
Hungary
Lithuania
Latvia
Ireland
Bulgaria
Greece
14.0
18.0
18.6
18.9
19.0
19.2
19.5
20.0
20.5
20.5
20.9
21.5
21.9
23.0
23.1
23.2
23.3
23.8
24.6
25.9
26.2
26.2
26.5
26.5
27.9
29.0
29.2
31.9
-25.9
-30.8
-9.7
n.a.
-18.8
n.a.
-11.8
-34.4
-14.9
n.a.
-27.0
-20.4
-11.3
-16.3
-5.3
-4.5
-13.7
-13.8
4.7
n.a.
-13.5
-17.4
-12.3
-5.4
-33.6
-12.1
n.a.
-8.9
Iceland
Norway
Switzerland
Turkey
14.3
19.0
20.4
25.4
40
30
20
% of population aged 15 years and over
10
-37.6
-40.6
-29.4
-20.9
0
-50
-40
-30
-20
-10
0
10
% change over the period
Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Infobase.
1 2 http://dx.doi.org/10.1787/888932704000
2.5.2. Females and males smoking daily, 2010 (or nearest year)
Males
Females
32
31
31
31
30
30
29
38
38
26
27
23
18
102
14
15
13
14
15
19
19
9
11
13
19
19
22
21
18
19
17
15
18
18
19
21
18
16
27
27
27
26
24
24
23
23
22
19
16
13
15
16
20
21
22
20
20
21
26
30
33
37
40
39
40
43
46
% of population aged 15 years and over
50
10
y
ke
Tu
r
nd
la
it z
er
d
ay
an
rw
Sw
el
No
Ic
Sw
De
ed
en
n
Lu m
a
Un xem r k
i te bo
ur
d
Ki
g
ng
do
Sl m
o
N e ven
i
th
er a
la
nd
Fi s
nl
an
Be d
lg
iu
m
M
al
ta
Fr
an
c
e
Sl Ge
r
ov
ak man
Re y
pu
b
Po lic
r tu
ga
Au l
st
ria
EU
27
Cz
ec
h It al
Re y
pu
bl
ic
Po
la
nd
Ir e
la
nd
Sp
a
Hu in
ng
ar
Ro y
m
an
i
Es a
to
ni
Cy a
pr
us
Gr
ee
Bu c e
lg
a
Li ria
th
ua
ni
a
La
tv
ia
0
Source: OECD Health Data 2012; Eurostat Statistics Database.
1 2 http://dx.doi.org/10.1787/888932704019
59
2.6. ALCOHOL CONSUMPTION AMONG ADULTS
The health burden related to excessive alcohol
consumption, both in terms of morbidity and mortality, is
considerable (Rehm et al., 2009; WHO Europe, 2012a). In
Europe, alcohol is the third leading risk factor for disease
and mortality after tobacco and high blood pressure. High
alcohol intake is associated with increased risk of heart,
stroke and vascular diseases, as well as liver cirrhosis and
certain cancers. Foetal exposure to alcohol increases the
risk of birth defects and intellectual impairments. Alcohol
also contributes to death and disability through accidents
and injuries, assault, violence, homicide and suicide. It is,
however, one of the major avoidable risk factors.
Although adult alcohol consumption per capita gives
useful evidence of long-term trends, it does not identify
sub-populations at risk from harmful drinking patterns.
Much of the burden of disease associated with alcohol
consumption occurs among persons who have an alcohol
dependence problem. The consumption of large quantities
of alcohol at a single session, termed “binge drinking”, is
also a particularly dangerous pattern of consumption
(Institute of Alcohol Studies, 2007), which is on the rise in
some countries and social groups, especially among young
males (see Indicator 2.1 “Smoking and alcohol consumption among children”).
The EU region has the highest alcohol consumption in
the world. Measured through monitoring annual sales data,
it stands at 10.7 litres of pure alcohol per adult on average
across EU member states, using the most recent data available (Figure 2.6.1). Leaving aside Luxembourg – because of
the high volume of purchases by non-residents in this
country – Austria, France, Latvia, Lithuania and Romania
reported the highest consumption of alcohol, with
12.0 litres or more per adult in 2010. At the other end of the
scale, southern European countries (Cyprus, Greece, Italy,
Malta) along with Nordic countries (Iceland, Sweden, and
Norway) have relatively low levels of consumption, in the
region of 7-8 litres of pure alcohol per adult. Turkey and the
Former Yugoslav Republic of Macedonia have rates well
below four litres.
The 2006 Commission Communication on an EU strategy to support member states in reducing alcohol-related
harm highlighted a number of priority themes, including
protecting children and young people, reducing harm from
alcohol-related road accidents, reducing the negative
impact of alcohol in the workplace, education on harmful
consumption, and developing a common alcohol evidence
base at EU level (EC, 2009a). In 2010, the World Health
Organization endorsed a global strategy to combat the
harmful use of alcohol, through direct measures such as
medical services for alcohol-related health problems, and
indirect measures, such as policy options for restricting the
availability and marketing of alcohol. This initiative was
boosted in 2011 by the adoption of a new European Action
Plan by the WHO Regional Office for Europe.
Although average alcohol consumption has gradually
fallen in many European countries over the past three
decades, it has risen in some others. There has been a degree
of convergence in drinking habits across the European
Union, with wine consumption increasing in many traditional beer-drinking countries and vice versa. The traditional
wine-producing countries of Italy, France and Spain, as well
as Greece, have seen their alcohol consumption per capita
fall substantially since 1980 (Figures 2.6.1 and 2.6.2). On the
other hand, alcohol consumption per capita in Cyprus,
Finland, Iceland and Ireland rose by a quarter or more
since 1980 although, in the case of Iceland and Cyprus, it
started from a low level and therefore remains relatively low.
Variations in alcohol consumption across countries
and over time reflect not only changing drinking habits but
also the policy responses to control alcohol use. Curbs on
advertising, sales restrictions and taxation have all proven
to be effective measures to reduce alcohol consumption
(Bennett, 2003; WHO Europe, 2012a). Strict controls on sales
and high taxation are mirrored by overall lower consumption in most Nordic countries.
60
Alcohol consumption is defined as annual sales of
pure alcohol in litres per person aged 15 years and
over. The methodology to convert alcohol drinks to
pure alcohol may differ across countries. Official
statistics do not i ncl u d e u n re co rd e d a lco h o l
consumption, such as home production.
Italy reports consumption for the population
14 years and over, resulting in a slight underestimation, and Sweden for 16 years and over. In some
countries (e.g. Luxembourg), national sales do not
accurately reflect actual consumption by residents,
since purchases by non-residents may create a significant gap between national sales and consumption.
2.6. ALCOHOL CONSUMPTION AMONG ADULTS
2.6.1. Alcohol consumption among population aged 15 years and over, 2010 and change, 1980-2010
Change per capita, 1980-2010
Italy
Sweden
Malta
Greece
Cyprus
Netherlands
Finland
Bulgaria
Poland
United Kingdom
Denmark
Slovenia
EU27
Slovak Republic
Belgium
Czech Republic
Estonia
Portugal
Spain
Hungary
Germany
Ireland
France
Austria
Lithuania
Romania
Latvia
Luxembourg
6.9
7.3
7.7
8.2
8.4
9.4
9.7
10.0
10.1
10.2
10.3
10.3
10.7
10.7
10.8
11.4
11.4
11.4
11.4
11.5
11.7
11.9
12.0
12.2
12.6
12.7
13.2
15.3
6.6
7.3
7.3
8.3
10.0
10.1
15
10
5
9
-38
35
-18
23
-10
-12
9
-12
-15
-26
-20
-3
-23
-38
-23
-16
24
-38
-16
17
1
12
Turkey
FYR of Macedonia
Norway
Iceland
Serbia
Montenegro
Switzerland
Croatia
1.5
3.7
20
Litres per capita
-59
0
-17
10
70
-26
-75
-50
-25
0
25
50
75
% change over period
Source: OECD Health Data 2012; WHO Global Information System on Alcohol and Health.
1 2 http://dx.doi.org/10.1787/888932704038
2.6.2. Trends in alcohol consumption, selected EU countries, 1980-2010
Finland
France
Italy
Sweden
EU27
Alcohol consumption (litres per capita)
20
15
10
5
1980
1985
1990
1995
2000
2005
2010
Source: OECD Health Data 2012; WHO Global Information System on Alcohol and Health.
1 2 http://dx.doi.org/10.1787/888932704057
61
2.7. OVERWEIGHT AND OBESITY AMONG ADULTS
The growth in overweight and obesity rates among
adults is a major public health concern. Obesity is a known
risk factor for numerous health problems, including hypertension, high cholesterol, diabetes, cardiovascular diseases,
respiratory problems (asthma), musculoskeletal diseases
(arthritis) and some forms of cancer. Mortality also increases
sharply once the overweight threshold is crossed (Sassi,
2010). Because obesity is associated with higher risks of
chronic illnesses, it is linked to significant additional health
care costs.
Based on latest available data, more than half (52%) of
the adult population in the European Union are overweight
or obese. The prevalence of overweight and obesity among
adults exceeds 50% in no less than 18 of 27 EU member
states. Obesity – which presents even greater health risks
than overweight – varies threefold among countries, from a
low of around 8% in Romania (and Switzerland) to over
25% in Hungary and the United Kingdom, although some of
the variations across countries may be due to different
methodologies in data collection (Figure 2.7.1). On average
across EU member states, 17% of the adult population is
obese.
There is little difference in the average obesity rate of
men and women (Figure 2.7.1). However, there is some
variation among individual countries, with more men than
women being obese in Malta, Iceland and Norway, whereas
a higher proportion of women are obese in Latvia, Turkey
and Hungary. The largest disparities were in Latvia, whereas
there was little, if any difference in male and female rates in
the Czech Republic, Greece and the United Kingdom.
The rate of obesity has doubled over the past 20 years
in many European countries (Figure 2.7.2), regardless of
previous levels. Obesity in 2010 is close to twice the rate
of 1990 in both France and the United Kingdom, even
though the rate in France is currently half that of the
United Kingdom.
The rise in obesity has affected all population groups,
but to varying extents. Evidence from a number of
countries, including Austria, England, France, Italy and
Spain, indicates that obesity tends to be more common in
disadvantaged socio-economic groups, and especially
among women (Sassi et al., 2009). There is also a relationship between the number of years of education and obesity,
with the most educated individuals displaying lower rates.
Again, the gradient in obesity is stronger in women than in
men (Sassi, 2010).
A number of behavioural and environmental factors
have contributed to the rise in overweight and obesity
62
rates in industrialised countries, including the widespread
availability of energy dense foods and more time spent being
physically inactive. Overweight and obesity have risen
rapidly in children in recent decades, reaching double-figure
rates in most countries (see Indicator 2.2 “Overweight and
obesity among children”).
Many countries have stepped up efforts to tackle the
root causes of obesity, embracing increasingly comprehensive strategies and involving communities and key stakeholders. Better informed consumers, the availability of
healthy food options, encouraging physical activity and a
focus on vulnerable groups are some of the fields for action
which have seen progress (EC, 2010a). There has also been
a new interest in the use of taxes on foods rich in fat and
sugar, with several governments (Denmark, Finland,
France, Hungary) recently passing legislation aiming to
change eating habits (OECD, 2012b).
Overweight and obesity are defined as excessive
weight presenting health risks because of the high
proportion of body fat. The most frequently used
measure is based on the body mass index (BMI), which
is a single number that evaluates an individual’s
weight in relation to height (weight/height2 , with
weight in kilograms and height in metres). Based on
the WHO classification (WHO, 2000), adults with a BMI
from 25 to 30 are defined as overweight, and those
with a BMI of 30 or over as obese. This classification
may not be suitable for all ethnic groups, who may
have equivalent levels of risk at lower or higher BMI.
The thresholds for adults are not suitable to measure
overweight and obesity among children.
For most countries, overweight and obesity rates
are self-reported through estimates of height and
weight from population-based health interview
surveys. The exceptions are the Czech and Slovak
Republics, Hungary, Ireland, Luxembourg and the
United Kingdom, where estimates are derived from
health examinations. These differences limit data
comparability. Estimates from health examinations
are generally higher and more reliable than from
health interviews.
2.7. OVERWEIGHT AND OBESITY AMONG ADULTS
2.7.1. Prevalence of obesity among adults, 2010 (or nearest year)
Self-reported data
Measured data
Males
7.9
10.3
11.4
11.5
12.8
12.9
12.9
13.4
13.8
14.7
15.4
15.6
15.6
15.8
16.0
16.6
16.8
16.9
16.9
16.9
17.3
19.7
21.0
22.5
22.9
23.0
26.1
28.5
Romania
Italy
Netherlands
Bulgaria
Austria
France
Sweden
Denmark
Belgium
Germany
Portugal
Cyprus
Finland
Poland
Spain
EU27
Slovenia
Estonia
Latvia
Slovak Republic
Greece
Lithuania
Czech Republic
Luxembourg
Malta
Ireland
United Kingdom
Hungary
8.0
Switzerland
Norway
Turkey
Iceland
7.7
8.1
10.0
16.9
21.0
40
30
% of adult population
20
10
Females
7.6
9.6
11.1
12.6
10.2
11.3
11.6
13.2
12.4
13.4
12.4
13.1
12.6
13.1
13.7
14.4
13.1
13.8
15.7
16.1
14.6
14.5
16.7
15.5
15.7
15.2
16.6
14.7
17.3
16.6
16.5
16.3
17.3
16.8
17.0
20.9
12.0
16.7
17.1
17.3
17.3
19.2
20.6
21.0
21.0
21.0
23.6
21.1
24.7
24.0
22.0
26.1
26.2
30.4
26.3
8.6
8.0
11.0
21.0
13.2
19.3
0
22.7
0
10
20
30
40
% of adult population
1 2 http://dx.doi.org/10.1787/888932704076
2.7.2. Increasing obesity rates among adults in European countries, 1990, 2000 and 2010 (or nearest years)
2000
2010
21.0
5.4
7.5
6.0
7.7
8.1
10.0
12.4
13.2
14.0
16.3
18.2
21.0
23.0
23.1
22.9
22.5
20.4
19.7
17.4
11.3
14.2
16.9
11.9
15.1
16.9
16.0
14.1
15.6
8.4
6.8
11.2
12.3
12.6
15.6
15.4
14.7
12.8
11.5
13.4
12.1
13.8
12.9
9.5
5.5
5.8
5.5
9.0
8.5
9.1
9.2
12.9
12.8
12.4
11.5
11.4
9.4
6.1
10
8.6
10.3
8.6
7.9
20
16.9
26.1
30
28.5
1990
%
40
d
an
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rw
la
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it z
No
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ng
Hu
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ar
m1
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do
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Ir e
la
ta
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ur
bo
m
Lu
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M
a
ni
ua
th
Li
pu
bl
ic
ic 1
bl
pu
Cz
ec
h
Re
ak
ov
Sl
Re
La
tv
ia
a
ni
to
Es
n
ai
Sp
d
an
Fi
nl
us
Cy
pr
l
ga
y
an
rm
Po
r tu
m
iu
lg
Be
Ge
k
ar
nm
De
Sw
ed
en
ce
an
Fr
ria
Au
st
ia
s
ar
lg
Bu
th
er
la
nd
ly
It a
Ne
Ro
m
an
ia
0
1. Hungary (1988, 2009), Ireland (2007), Luxembourg, the Slovak Republic (2008) and the United Kingdom figures are based on health examination
surveys, rather than health interview surveys.
1 2 http://dx.doi.org/10.1787/888932704095
63
2.8. FRUIT AND VEGETABLE CONSUMPTION AMONG ADULTS
Nutrition is an important determinant of health.
Inadequate consumption of fruit and vegetables is one
factor that can play a role in increased morbidity. Proper
nutrition assists in preventing a number of obesity-related
chronic conditions, including cardiovascular disease,
hypertension, Type 2 diabetes, stroke, certain cancers,
musculoskeletal disorders and a range of mental health
conditions. A European Commission White Paper advocated increasing the consumption of fruit and vegetables as
one of a number of tools to offset a worsening trend of poor
diets and low physical activity (EC, 2007).
In response to a health survey question asking “How
often do you eat fruit?”, the percentage of adults consuming fruit daily varied from 45% in Bulgaria and Romania, to
75% in Italy, Malta and Slovenia, and 84% in Switzerland
around 2008 (Figure 2.8.1). Across the 19 EU member states
providing data, an average 63% of adults ate fruit daily.
Females ate fruit more often than males, with the largest
gender differences in Denmark, the Slovak Republic and
Germany (23, 20 and 19 percentage points respectively). In
Mediterranean countries (Cyprus, Greece, Italy, Malta,
Spain and Turkey), gender differences were much smaller,
at under 10%.
Among different age groups, older persons aged
65 and over were more likely to eat fruit, with consumption
lowest among young people aged 15-24 years, except in
Bulgaria and Romania, where young people ate the most
(see also Indicator 2.3 “Fruit and vegetable consumption
among children”). Fruit consumption also varies by socioeconomic status, generally being highest among persons
with higher educational levels (Figure 2.8.3). However, this
was not the case in Mediterranean countries (Cyprus,
Malta, Spain, Greece), where lower educated persons ate
fruit more often.
Daily vegetable consumption ranged from around
50% in Estonia, Germany, Malta and the Slovak Republic to
75% in France and Slovenia, with Belgium and Ireland
highest at 85% and 95% respectively (Figure 2.8.2). The
average across 18 countries was the same as for fruit, 63%.
Again, more females reported eating vegetables daily,
except in Bulgaria and Ireland, where rates were similar. In
the Czech and Slovak Republics, Germany, Italy, Malta and
Spain, gender differences exceeded 10%.
Patterns of vegetable consumption among age groups
and educational groups are similar to those for fruit. Older
persons more commonly ate vegetables daily, except in
Bulgaria, the Czech Republic, Latvia and Romania. Highly
educated persons ate vegetables more often, although the
64
difference between educational groups was small in
Belgium, Cyprus, Italy, Greece, Slovenia and the Slovak
Republic (Figure 2.8.4). Differences exceeded 20% in
Bulgaria, Latvia and Romania.
The availability of fruit and vegetables is the major
determinant of consumption. Despite high variability
between countries, vegetable and especially fruit availability is higher in southern European countries, with cereals
and potatoes more available in central and eastern
European countries. Fruit and vegetable availability also
tends to be higher in families where household heads have
a higher level of education (Elmadfa, 2009).
The promotion of fruit and vegetable consumption,
especially in schools and the workplace, features in the
EU platform for action on diet, physical activity and health,
a forum for European-level organisations, ranging from the
food industry to consumer protection NGOs, willing to
commit to tackling current trends in diet and physical
activity (EC, 2011a). Policy makers and government representatives share ideas and best practice on the promotion
of fruit and vegetable consumption in the High Level Group
on Nutrition and Physical Activity.
Estimates of daily fruit and vegetable consumption
are derived from national and European Health
Interview Survey questions, conducted in many EU
member states between 2006 and 2010. Typically,
respondents were asked “How often do you eat
fruit (excluding juice)?” and “How often do you eat
vegetables or salad (excluding juice and potatoes)?”
Response categories included: Twice or more a day/
Once a day/Less than once a day but at least four
times a week/Less than four times a week, but at least
once a week/Less than once a week/Never.
Data for France and Switzerland include juices,
soups and potatoes. Data rely on self-report, and are
subject to errors in recall. The same survey also asked
for information on age, sex and educational level.
Data are not age-standardised, with aggregate country estimates representing crude rates among respondents aged 15 years and over in all countries, except
Germany which is 18 years and over.
2.8. FRUIT AND VEGETABLE CONSUMPTION AMONG ADULTS
2.8.1. Daily fruit eating among adults,
Males
2.8.2. Daily vegetable eating among adults,
Females
Slovenia
Males
82
67
Italy
69
Ireland
70
Czech Republic
52
Greece
62
Hungary
62
Romania
59
Denmark
39
Bulgaria
39
Romania
41
78
89
20
40
80
56
48
51
48
37
56
55
54
83
Turkey
60
57
43
Switzerland
53
51
0
58
44
Germany
Switzerland
Turkey
59
59
Estonia
51
49
65
64
53
Malta
64
48
62
Slovak Republic
66
57
65
60
Bulgaria
67
67
53
Italy
68
58
66
66
Greece
68
63
Estonia
59
Poland
69
Cyprus
Poland
EU18
Czech Republic
57
Latvia
59
71
59
Belgium
Latvia
72
79
70
67
56
74
53
EU19
66
Spain
74
66
France
Cyprus
75
54
Germany
71
100
%
87
80
73
Slovenia
75
Spain
82
France
78
61
Slovak Republic
Belgium
78
57
Hungary
96
95
Ireland
79
73
Malta
Females
60
0
20
40
60
91
63
80
100
%
Source: Eurostat Statistics Database and national health interview surveys.
1 2 http://dx.doi.org/10.1787/888932704114
1 2 http://dx.doi.org/10.1787/888932704133
2.8.3. Daily fruit eating among adults,
by educational level, 2008 (or nearest year)
2.8.4. Daily vegetable eating among adults,
by educational level, 2008 (or nearest year)
Lowest educational level
Highest educational level
%
100
80
80
70
70
60
60
50
50
40
40
30
30
Sl
De
1 2 http://dx.doi.org/10.1787/888932704152
Highest educational level
ov Ge
ak rm
Re a n
pu y
bl
M ic
a
Es lt a
to
ni
a
C z H It a
e c un l y
h g
Re ar
pu y
bl
Sp ic
ai
EU n
Gr 17
Ro e e c
m e
a
C y ni a
p
Bu r us
lg
a
Po r i a
la
n
La d
Sl t v i
ov a
en
Fr i a
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Be ce
lg
iu
m
90
nm
Gr a r k
e
C y ece
Bu pr u
l s
Ge gar
rm ia
Es any
to
Cz
e c B e ni a
Sl h l gi
ov Re um
a k pu
Re bl
pu ic
bl
E ic
Ro U 1
m 8
an
Sp i a
Po a in
la
Fr nd
an
c
M e
Hu a l t
ng a
a
La r y
tv
ia
Sl It al
ov y
en
ia
T
Sw u
i t z r ke
er y
la
nd
90
Lowest educational level
Sw Tu
i t z r ke
er y
la
nd
%
100
1 2 http://dx.doi.org/10.1787/888932704171
65
© OECD 2012
Chapter 3
Health care resources and activities
3.1.
Medical doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
68
3.2.
Consultations with doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
70
3.3.
Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
72
3.4.
Medical technologies: CT scanners and MRI units. . . . . . . . . . . . . . . .
74
3.5.
Hospital beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
76
3.6.
Hospital discharges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
78
3.7.
Average length of stay in hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
80
3.8.
Cardiac procedures (coronary angioplasty) . . . . . . . . . . . . . . . . . . . . . .
82
3.9.
Cataract surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
84
3.10. Hip and knee replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
86
3.11. Pharmaceutical consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
88
3.12. Unmet health care needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
90
67
3.1. MEDICAL DOCTORS
In many European countries, there are concerns about
current or future shortages of doctors, in general or more
specifically for certain categories of doctors or in certain
locations (e.g. in rural and remote areas). This section provides data on the number of doctors per capita in European
countries in 2010 and its evolution over the past decade, as
well as a disaggregation between generalists and specialists.
In 2010, Greece had, by far, the highest number of
doctors per capita, with 6.1 doctors per 1 000 population,
nearly twice the EU average of 3.4. Following Greece was
Austria, with 4.8 doctors per 1 000 population. The number
of doctors per capita was also relatively high in Norway,
Portugal (although the number reported is an overestimation as it comprises all doctors licensed to practice,
including some who may not be practising), Sweden,
Switzerland and Spain. The number of doctors per capita
was the lowest in Montenegro and Turkey, followed by
Poland, Romania and Slovenia (Figure 3.1.1).
Since 2000, the number of physicians per capita has
increased in all European countries, except in France, Estonia
and Poland. On average across EU member states, physician
density grew from 2.9 doctors per 1 000 population in 2000
to 3.4 in 2010. The growth rate was particularly rapid in
Greece, which started from the highest level in 2000, thereby
increasing the gap with other countries, and the United
Kingdom, which started from the second lowest level in 2000,
thereby narrowing the gap with other European countries.
In Greece, the number of doctors per capita has stabilised since the beginning of the crisis in 2008, following
strong growth between 2000 and 2008.
In the United Kingdom, the number of doctors per
capita has gone up steadily over the past decade, from
2.0 doctors per 1 000 population in 2000 to 2.7 in 2010 (and
2.8 in 2011). The number of new registrations of foreigntrained doctors increased up to 2003 when it peaked at
about 14 000, but has declined since then to about 5 000
in 2010 and 2011 (General Medical Council, 2012). At the
same time, the number of new graduates from medical
schools in the United Kingdom increased, from about 4 600
in 2003 to 5 800 in 2010 and in 2011, gradually exceeding
the number of new registrations of foreign-trained physicians (OECD, 2012a).
In France, the number of doctors per capita has not
increased over the past decade, and it is expected to
decrease until 2020, following the reduction in the number
of new entrants and graduates from medical schools
during the 1980s and 1990s (DREES, 2009).
68
In nearly all countries, the balance between generalist
and specialist doctors has changed over the past few
decades, with the number of specialists increasing much
more rapidly. As a result, there are more specialists than
generalists in most countries, except in Ireland, Malta,
Portugal and Norway (Figure 3.1.2). This may be explained
by a lesser interest in the traditional mode of practice of
general practitioners (family doctors) given the workload
and constraints attached to it. In addition, in many
countries, the remuneration gap between generalists and
specialists has widened (Fujisawa and Lafortune, 2008).
The slow or negative growth in the number of generalists
per capita raises concerns about access to primary care for
certain population groups. In response to this shortage,
many countries have taken steps to improve the number of
training posts and attractiveness of general practice. For
example, in France, the number of interns in general
practice has increased markedly in recent years, with
around half of all internships allocated to general practice
in 2010 and 2011 (DREES, 2012). A number of countries are
also considering the development of new roles for other
health care providers, such as advanced practice nurses, to
respond to growing demands for primary care (Delamaire
and Lafortune, 2010).
Practising physicians are defined as doctors who are
providing care directly to patients. In some countries,
the numbers also include doctors working in administration, management, academic and research positions (“professionally active” physicians), adding
another 5-10% of doctors. Portugal reports all physicians entitled to practice, resulting in an even greater
overestimation.
Generalists include general practitioners (“family
doctors”) and other generalist/non-specialist
practitioners who may be working in hospitals or
outside hospitals. Specialists include paediatricians,
gynaecologists and obstetricians, psychiatrists,
medical specialists, surgical specialists and other
specialties. Other physicians include interns/residents
if they are not reported in the field in which they are
training, and doctors who are not classified elsewhere.
3.1. MEDICAL DOCTORS
3.1.1. Practising doctors per 1 000 population, 2010 and change between 2000 and 2010 (or nearest year)
Greece 1
Austria
Portugal 2
Sweden
Spain
Germany
Lithuania
Bulgaria
Italy
Czech Republic
Denmark
EU27
Slovak Republic1
Finland1
France 1
Estonia
Ireland1
Malta
Cyprus
Belgium
Netherlands1
Latvia
Hungary
Luxembourg
United Kingdom
Slovenia
Romania
Poland
6.1
4.8
3.8
3.8
3.8
3.7
3.7
3.7
3.7
3.6
3.5
3.4
3.3
3.3
3.3
3.2
3.1
3.1
3.0
2.9
2.9
2.9
2.9
2.8
2.7
2.4
2.4
2.2
3.8
3.6
2.8
2.8
2.7
2.1
1.7
4
2.1
2.3
n.a.
1.4
0.2
1.0
n.a.
0.6
2.0
1.4
n.a.
1.3
0.0
-0.1
n.a.
n.a.
1.5
0.3
2.0
0.1
n.a.
2.6
3.3
1.2
2.1
-0.1
Norway
Switzerland
Iceland1
Serbia
Croatia
FYR of Macedonia1
Montenegro
Turkey1
4.1
8
6
3.5
2.2
2
0
2.8
n.a.
0.5
1.3
1.7
n.a.
1.1
3.0
-2
0
2
4
Average annual growth rate (%)
1. Data include not only doctors providing direct care to patients, but also those working in the health sector as managers, educators, researchers, etc.
(adding another 5-10% of doctors).
2. Data refer to all doctors who are licensed to practice.
Source: OECD Health Data 2012; Eurostat Statistics Database; WHO European Health for All Database.
1 2 http://dx.doi.org/10.1787/888932704190
3.1.2. Generalists and specialists as a share of all doctors, 2010 (or nearest year)
Generalists1
Specialists 2
Medical doctors not further defined
67
67
33
64
62
16
16
73
18
60
56
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77
20
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80
82
76
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20
69
79
21
74
66
70
71
30
29
62
46
50
35
60
32
64
36
58
60
42
38
57
43
51
50
48
80
40
34
% of total doctors
100
1. Generalists include general practitioners/family doctors and other generalist (non-specialist) medical practitioners.
2. Specialists include paediatricians, obstetricians/gynaecologists, psychiatrists, medical, surgical and other specialists.
1 2 http://dx.doi.org/10.1787/888932704209
69
3.2. CONSULTATIONS WITH DOCTORS
Consultations with doctors can take place in doctors’
offices or clinics, in hospital outpatient departments or, in
some cases, in patients’ own homes. In many European
countries (e.g. Denmark, Italy, the Netherlands, Norway,
Portugal, the Slovak Republic, Spain and the United Kingdom),
patients are required or given incentives to consult a general
practitioner (GP) about any new episode of illness. The GP
may then refer them to a specialist, if indicated. In other
countries (e.g. Austria, the Czech Republic and Iceland),
patients may approach specialists directly.
The number of doctor consultations per person per
year is highest in Hungary, the Czech Republic and the
Slovak Republic, while it is lowest in Cyprus, Malta and
Sweden (Figure 3.2.1). The EU average is 6.3 consultations
per person per year, with most member states reporting
4 to 7 visits per person per year. Cultural factors appear to
play a role in explaining some of the variations across
countries, although certain health system characteristics
may also play a role. Some countries which pay their
doctors mainly by fee-for-service tend to have aboveaverage consultation rates (e.g. Belgium and Germany),
while other countries that have mostly salaried doctors
tend to have below-average rates (e.g. Finland and Sweden).
In Sweden, the low number of doctor consultations
may also be explained partly by the fact that nurses play an
important role in primary care (Bourgueil et al., 2006).
Similarly, in Finland, nurses and other health professionals
play an important role in providing primary care to patients
in health centres, lessening the need for consultations with
doctors (Delamaire and Lafortune, 2010).
In many European countries, the average number of
doctor consultations per person has increased since 2000
(Figure 3.2.1). This is consistent with the increase in the
number of doctors per capita in most countries over the
past decade (see Indicator 3.1). In the Czech Republic and
the Slovak Republic, there has been a substantial reduction
in the number of doctor consultations per capita over the
past decade, although the number remains well above
the EU average. In Spain also, there has been a marked
decline in the number of doctor consultations per person
since 2000.
The number of doctor consultations varies not only
across countries, but also among different population
groups in each country. This is particularly the case for
consultations with medical specialists. A recent OECD study,
using health interview surveys carried out between 2006
and 2009, provides evidence on inequality in doctor consultations by income group in a number of European countries
(Devaux and de Looper, 2012). Figure 3.2.2 shows the
horizontal inequity index – a measure of inequality in health
care use adjusted for differences in need – regarding the
probability of having at least one visit to a generalist or a
specialist during the year. The probability favours low
income groups when it is below zero, and high income
groups when it is above zero. The index is adjusted for
differences in need for health care because health problems
are more frequent and severe among lower income groups.
70
The probability of a generalist (GP) visit is equally distributed
in most countries (Figure 3.2.2). When inequality does exist,
it is often positive, indicating a pro-rich distribution, but the
degree of inequality is small. Lower income people, however,
consult a GP more frequently (results not shown). A different
story emerges for specialist visits – in nearly all countries,
high income people are more likely to see a specialist than
those with low income (Figure 3.2.2), and also more
frequently.
Consultations with doctors refer to the number of
contacts with physicians, including both generalists
and specialists. There are variations across countries in
the coverage of different types of consultations, notably
in outpatient departments of hospitals. The data come
mainly from administrative sources, although in some
countries (Ireland, Italy, the Netherlands, Spain,
Switzerland and the United Kingdom) the data come
from health interview surveys. Estimates from administrative sources tend to be higher than those from
surveys because of problems with recall and nonresponse rates.
The figures for the Netherlands exclude contacts for
maternal and child care. The data for Portugal exclude
visits to private practitioners, which is also largely the
case in Malta, while those for the United Kingdom
exclude consultations with specialists outside hospital.
In Luxembourg, doctors consultations outside the
country are not included (these consultations account
for a higher number than in other countries). In
Germany, the data include only the number of cases of
physicians’ treatment according to reimbursement
regulations under the Social Health Insurance Scheme
(a treatment only counts the first contact over a threemonth period, even if the patient consults a doctor
more often). Telephone contacts are included in several
countries (e.g. the Czech Republic, Ireland, Spain and the
United Kingdom).
The horizontal inequity indices shown here refer to
the probability of a visit to a generalist or a specialist
in a given year by income group. The data come from
health interview surveys conducted between 2006
and 2009. Inequalities in doctor consultations are
assessed in terms of household income. The number
of doctor consultations is adjusted for need, based on
self-reported information about health status. Differing survey questions and response categories may
affect cross-national comparisons. The measures
used to grade income can also vary. Caution is therefore needed when interpreting inequalities in doctor
consultations across countries.
3.2. CONSULTATIONS WITH DOCTORS
3.2.1. Doctors consultations per capita, 2010 and change between 2000 and 2010 (or nearest year)
Hungary
Slovak Republic
Czech Republic
Germany
Belgium
Spain
Lithuania
Austria
France
Netherlands
Poland
Slovenia
EU24
Estonia
Luxembourg
Latvia
United Kingdom
Romania
Denmark
Finland
Portugal
Ireland
Malta
Sweden
Cyprus
11.7
11.3
11.0
8.9
7.7
7.5
6.9
6.9
6.7
6.6
6.6
6.4
6.3
6.0
6.0
5.6
5.0
4.7
4.6
4.3
4.1
3.8
2.9
2.9
2.1
7.3
6.3
6.2
5.2
4.4
4.0
6
-1.3
2.1
-0.3
-1.8
0.8
0.3
-1.1
1.1
1.1
n.a.
0.1
-0.5
-0.2
1.6
-0.6
-0.8
0.9
0.0
1.6
n.a.
1.7
0.4
0.7
Serbia
Turkey
Iceland
Croatia
Norway
Montenegro
Switzerland
8.1
12
9
Annual consultations per capita
0.5
-3.1
3
-0.9
n.a.
0.8
-1.2
n.a.
3.6
3.3
0
-4
-2
0
2
4
1 2 http://dx.doi.org/10.1787/888932704228
3.2.2. Inequity index for the probability of a visit in the past 12 months, adjusted for need, 2009 (or nearest year)
ce
k1
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Fr
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0.10
k1
0.10
ic
Inequity index for specialist visits
0.15
Re
Inequity index for GP visits
0.15
1. Visits in the past three months in Denmark.
Source: Devaux and de Looper (2012).
1 2 http://dx.doi.org/10.1787/888932704247
71
3.3. NURSES
Nurses are usually the most numerous health
profession, outnumbering physicians in most European
countries. Nurses play a critical role in providing health
care not only in traditional settings such as hospitals and
long-term care institutions but increasingly in primary care
(especially in offering care to the chronically ill) and in
home care settings. However, there are concerns in many
countries about shortages of nurses, and these concerns
may well intensify in the future as the demand for nurses
continues to increase and the ageing of the “baby boom”
generation precipitates a wave of retirements among
nurses. These concerns have prompted many countries to
increase the training of new nurses combined with efforts
to increase the retention of nurses in the profession
(OECD, 2008a).
In 2010, there were over 15 nurses per 1 000 population
in Switzerland, Denmark and Belgium. Turkey had the
fewest nurses, followed by Greece and the Former Yugoslav
Republic of Macedonia (all these countries have fewer than
four nurses per 1 000 population). The EU average was close
to eight nurses per 1 000 population.
Since 2000, the number of nurses per capita has
increased in all European countries, except in Lithuania
and the Slovak Republic. The increase was particularly
large in Portugal, Spain and Turkey. In Denmark and France,
there was also a fairly large increase in the number of
nurses, rising by over 25% in absolute terms since 2000. In
Estonia, the absolute number of nurses increased up
to 2008, but has decreased since then; this has led to a
reduction in the number of nurses per 1 000 population
from 6.4 in 2008 to 6.1 in 2010.
In 2010, the number of nurses per doctor ranged from
more than four in Denmark, Finland, Ireland and Switzerland
to less than one nurse per doctor in Greece and one in Italy
and Turkey (Figure 3.3.2). The average across EU member
states is two-and-a-half nurses per doctor, with many
countries reporting between two to four nurses per doctor. In
Greece and Italy, there is evidence of an oversupply of doctors
and undersupply of nurses, resulting in an inefficient
allocation of resources (OECD, 2009; Chaloff, 2008).
A recent survey of nurses working in hospitals in
12 European countries provides evidence about their job
satisfaction and intention to leave the profession, as well
as their perception of the quality of care provided in their
hospital. This survey found large variations in rates of job
dissatisfaction among nurses, ranging from 11% in the
Netherlands up to 56% in Greece, and their intention to
leave their positions, with rates varying from 19% in the
Netherlands up to almost 50% in Finland and Greece.
Nurses in Greece also reported a particularly high level of
burnout, and nearly half described their hospital wards as
providing poor or fair quality of care only. In all countries,
72
higher nurse staffing levels and better work environments
in hospital were significantly associated with better quality
and safety of care for patients, and higher job satisfaction
for nurses (Aiken et al., 2012).
In response to shortages of general practitioners,
some countries have taken the initiative to develop more
advanced roles for nurses to ensure proper access to primary care. Evaluations of the experience with (advanced)
nurse practitioners in Finland and the United Kingdom, as
well as in Canada and the United States, show that they
can improve access to care and reduce waiting times, while
providing the same quality of care as doctors for patients
with minor illnesses or those requiring routine follow-up.
Most evaluations find a high patient satisfaction rate, with
the impact on cost being either cost-reducing or costneutral. The development of new advanced roles for nurses
requires the implementation of more advanced education
and training programmes to ensure that they have proper
skills (often at the master’s level at university), and also
often involve legislative or regulatory changes to remove
any barrier to the extension in their scope of practice
(Delamaire and Lafortune, 2010).
The number of nurses includes those employed in
public and private settings, who are providing
services directly to patients (“practising”) and/or are
working as managers, educators or researchers (“professionally active”). Data for Belgium and Italy refer to
all nurses who are licensed to practice, regardless of
whether they are practising/professionally active or
not (this is resulting in a large overestimation).
In countries where there are different levels of
nurses, the data include both “professional nurses”
who have a higher level of education and perform
higher level tasks and “associate professional nurses”
who have a lower level of education but are nonetheless recognised and registered as nurses.
Midwives, as well as nursing aids who are not
recognised as nurses, are normally excluded. However, some countries include midwives because they
are considered as specialist nurses.
Austria reports only nurses working in hospitals,
resulting in an underestimation. Data for Germany
does not include about 270 000 nurses (representing
an additional 30% of nurses) who have three years of
education and are providing services for the elderly.
3.3. NURSES
3.3.1. Practising nurses per 1 000 population, 2010 and change between 2000 and 2010
Denmark
Belgium1
Ireland 2
Germany
Luxembourg
Sweden
United Kingdom
Finland
France 2
Netherlands
Slovenia
Czech Republic
EU27
Austria 3
Lithuania
Malta
Italy1
Hungary
Estonia
Slovak Republic 2
Portugal 2
Poland
Romania
Spain
Cyprus
Latvia
Bulgaria
Greece 2
15.4
15.1
13.1
11.3
11.1
11.0
9.6
9.6
8.5
8.4
8.2
8.1
7.9
7.7
7.0
6.5
6.3
6.2
6.1
6.0
5.7
5.3
5.2
4.9
4.9
4.7
4.2
3.3
14.5
14.4
5.8
5.3
5.1
3.6
1.6
10
1.0
1.6
n.a.
1.2
n.a.
0.4
2.4
1.2
1.8
0.6
1.2
0.7
-0.9
n.a.
1.2
1.7
0.3
-2.1
5.0
0.7
n.a.
3.2
1.5
0.3
0.9
2.2
Switzerland
Iceland 2
Norway
Serbia
Croatia
Montenegro
FYR of Macedonia 2
Turkey2
16.0
20
15
2.5
n.a
5
0
2.2
0.9
2.2
1.1
1.4
0.3
2.4
4.2
-3
0
3
6
1. Data refer to all nurses who are licensed to practice.
2. Data include not only nurses providing direct care to patients, but also those working in the health sector as managers, educators, researchers, etc.
3. Austria reports only nurses employed in hospitals.
1 2 http://dx.doi.org/10.1787/888932704266
3.3.2. Ratio of nurses to physicians, 2010 (or nearest year)
6
5
4.4
4
4.3
4.2
4.2
4.0
4.0
3.5
3.5
3.4
3.1
3
4.0
3.0
2.9
2.6
2.5
2.4
2.5
2.3
2.2
2.2
2.1
1.9
2
1.9
2.0
1.8
1.6
1.6
1.6
1
1.5
1.3
1.9
1.4
1.1
1.0
1.0
0.5
nm
De
Fi
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nl k
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Fr n
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1. For those countries which have not provided data for practising nurses and/or practising physicians, the numbers relate to the same concept
(“professionally active” or “licensed to practice”) for both nurses and physicians, for the sake of consistency.
1 2 http://dx.doi.org/10.1787/888932704285
73
3.4. MEDICAL TECHNOLOGIES: CT SCANNERS AND MRI UNITS
New medical technologies are improving diagnosis
and treatment, but they are also increasing health spending. This section presents data on the availability and use
of two diagnostic technologies: computed tomography (CT)
scanners and magnetic resonance imaging (MRI) units.
CT scanners and MRI units help physicians diagnose a
range of conditions by producing images of internal organs
and structures of the body. Unlike conventional radiography and CT scanning, MRI exams do not expose patients
to ionising radiation.
The availability of CT scanners and MRI units has
increased rapidly in most European countries over the past
two decades. For example, in the Netherlands, the number
of MRI units per capita was multiplied by ten between 1990
and 2010, while the number of CT scanners nearly doubled.
Similarly, in Italy, the number of MRI scanners per capita
was increased by nearly six times between 1997 and 2010,
and the number of CT scanners more than doubled.
In 2010, Greece, Italy and Cyprus had the highest
number of MRI and CT scanners per capita among
EU member states. Iceland and Switzerland also had significantly more MRI and CT scanners than the EU average
(Figures 3.4.1 and 3.4.2). The numbers of MRI units and CT
scanners per population were the lowest in Hungary and
Romania.
There is no general guideline or benchmark regarding
the ideal number of CT scanners or MRI units per population. However, if there are too few units, this may lead to
access problems in terms of geographic proximity or
waiting times. If there are too many, this may result in an
overuse of these costly diagnostic procedures, with little if
any benefits for patients.
Data on the use of these diagnostic scanners are
available only for a smaller group of countries. Based on
this more limited country coverage, the number of CT and
MRI exams per capita is the highest in Greece, consistent
with the fact that Greece also has the highest number of
these two types of scanners. The number of MRI exams per
capita is also above average in Germany and Luxembourg,
as well as in Iceland and Turkey. It is the lowest in Ireland
and Slovenia, although in these two countries only
CT exams and MRI exams carried out in hospitals are
reported, resulting in an underestimation.
74
In Greece, most CT and MRI scanners are installed in
privately-owned diagnostic centres and only a minority are
found in public hospitals. While there are no guidelines
regarding the use of CT and MRI scanners in Greece (Paris
et al., 2010), since late 2010, a ministerial decree has established certain criteria concerning the purchase of imaging
equipment in the private sector (Official Gazette, No. 1918/10,
December 2010). One of the main criteria is based on a
minimum threshold of population density (30 000 population
for CT scanners and 40 000 for MRIs). These regulations do
not apply to the public sector.
Clinical guidelines have been developed in some
European countries to promote a more rational use of such
diagnostic technologies (OECD, 2010b). In the United
Kingdom, since the creation of the Diagnostic Advisory
Committee by the National Institute for Health and Clinical
Excellence (NICE), a number of guidelines have been issued
on the appropriate use of MRI and CT exams for different
purposes (NICE, 2012).
For MRI units and CT scanners, the numbers of
equipment per million population are reported.
MRI exams and CT exams relate to the number of
exams per 1 000 population. In most countries, the
data cover equipment installed both in hospitals and
the ambulatory sector.
However, there is only partial coverage for some
countries. MRI units and CT scanners outside hospitals
are not included in some countries (Belgium, Germany
and Spain, as well as Switzerland for MRI units). For
the United Kingdom, the data only include scanners in
the public sector. MRI and CT exams outside hospitals
are not included in certain countries (Austria, Ireland,
Slovenia, Spain and the United Kingdom). Furthermore, MRI and CT exams for Ireland only cover public
hospitals. The Netherlands only report data on
publicly-financed exams.
3.4. MEDICAL TECHNOLOGIES: CT SCANNERS AND MRI UNITS
3.4.1. MRI units, 2010 (or nearest year)
Hospital
Outside hospital
Greece
Italy
Cyprus
Finland
Austria
Denmark
Luxembourg
Ireland
Netherlands
Spain1
Belgium1
EU23
Germany1
Portugal
Estonia
Latvia
Malta
France
Slovak Republic
Czech Republic
United Kingdom 2
Poland
Lithuania
Slovenia
Bulgaria
Hungary
Romania
3.4.2. CT scanners, 2010 (or nearest year)
Total (no breakdown)
Hospital
22.6
22.4
19.9
18.7
18.6
15.4
13.8
12.5
12.2
10.7
10.7
10.3
10.3
9.2
8.2
7.6
7.2
7.0
6.8
6.3
5.9
4.7
4.6
4.4
4.1
3.0
2.4
Iceland
Switzerland1
Turkey
Croatia
22.0
17.8
9.5
7.2
0
5
10
15
Outside hospital
Greece
Cyprus
Italy
Malta
Austria
Bulgaria
Denmark
Portugal
Latvia
Luxembourg
Finland
EU23
Germany1
Lithuania
Estonia
Ireland
Spain1
Czech Republic
Poland
Slovak Republic
Belgium1
Slovenia
Netherlands
France
United Kingdom 2
Hungary
Romania
34.3
33.6
31.6
31.3
29.8
29.7
27.6
27.4
27.2
25.6
21.1
20.4
17.7
17.7
15.7
15.6
15.0
14.5
14.3
13.8
13.2
12.7
12.3
11.8
8.2
7.3
5.8
Iceland
Switzerland
Croatia
Turkey
20
25
Per million population
37.7
32.6
15.8
12.4
0
8
16
24
32
40
Per million population
Note: The EU average does not include countries which only report
equipment in hospital.
1. Equipment outside hospital is not included.
2. Any equipment in the private sector is not included.
Note: The EU average does not include countries which only report
equipment in hospital.
1. Equipment outside hospital is not included.
2. Any equipment in the private sector is not included.
1 2 http://dx.doi.org/10.1787/888932704304
1 2 http://dx.doi.org/10.1787/888932704323
3.4.3. MRI exams, 2010 (or nearest year)
3.4.4. CT exams, 2010 (or nearest year)
Hospital
Outside hospital
Greece
Germany
Luxembourg
France
Denmark
Belgium
Netherlands
Estonia
Austria1
Spain1
United Kingdom1
Czech Republic
Slovak Republic
Hungary2
Ireland1
Slovenia1
Hospital
97.9
95.2
79.6
60.2
57.5
52.8
49.1
48.1
47.6
45.6
40.8
33.5
33.2
31.7
17.3
2.0
Turkey
Iceland
79.5
74.2
0
20
40
60
80
100
Outside hospital
Greece
Estonia
Luxembourg
Belgium
Austria1
France
Germany
Denmark
Slovak Republic
Czech Republic
Spain1
United Kingdom1
Hungary2
Ireland1
Netherlands
Slovenia1
320.4
275.4
188.0
179.3
145.5
145.4
117.1
105.2
89.2
86.5
82.8
76.4
76.2
75.4
66.0
12.8
Iceland
Turkey
159.8
103.5
0
70
140
1. Exams outside hospital are not included.
2. Exams in hospital are not included.
1. Exams outside hospital are not included.
2. Exams in hospital are not included.
Source: OECD Health Data 2012.
1 2 http://dx.doi.org/10.1787/888932704342
210
280
350
1 2 http://dx.doi.org/10.1787/888932704361
75
3.5. HOSPITAL BEDS
The number of hospital beds provides an indication of
the resources available for delivering services to inpatients
in hospitals. This section presents data on the total number
of hospital beds, including those allocated for curative care,
psychiatric care, long-term care and other types of care. It
does not capture the capacity of hospitals to provide sameday emergency or elective interventions.
Over the past ten years, the number of hospital beds
per population has decreased in all European countries,
except Greece and Turkey. On average across EU member
states, the number fell by close to 2% per year, coming down
from 6.5 beds per 1 000 population in 2000 to 5.3 in 2010
(Figure 3.5.1). This reduction in the number of hospital beds
has been accompanied by a reduction in average length of
stays (Indicator 3.7) and, in some countries, a reduction in
hospital admissions and discharges (Indicator 3.6). The
reduction in the number of hospital beds has been particularly pronounced in Latvia (coming down from 8.7 beds
per 1 000 population in 2000 to 5.3 in 2010), Estonia, Italy and
Norway.
In all countries, progress in medical technologies has
enabled a move to same-day surgery and a reduced need for
long hospitalisation. In many countries, the financial and
economic crisis which started in 2008 also provided a further
stimulus to reduce hospital capacity as part of policies to
reduce public spending on health (European Observatory on
Health Systems and Policies, 2012). For example, in Ireland,
policies to reduce costs in the hospital sector in the aftermath of the crisis included a reduction in hospital beds, and
incentives to reduce the length of stays in hospitals and
increase day care (Thomas and Burke, 2012).
In 2010, Austria and Germany had the highest number
of hospital beds per capita, with around eight beds per
1 000 population (Figure 3.5.1). The high supply of hospital
beds in these two countries is associated with a large
number of hospital admissions/discharges, as well as long
average length of stays in Germany. Turkey had the lowest
number of beds per capita, although their number
increased markedly over the past decade. Ireland, Sweden
and the United Kingdom also have a relatively low number
of hospital beds (although the data in the United Kingdom
and Ireland do not include beds in private hospitals).
More than two-thirds of hospital beds are allocated for
curative care on average across EU member states
(Figure 3.5.2). The rest of the beds are allocated for psychiatric care (15%), long-term care (8%) and other types of care
(8%). However, in some countries, the share of beds
allocated for psychiatric care and long-term care is much
greater than the average. In Finland, a greater share of
hospital beds is allocated for long-term care (32%) than for
curative care (30%), because local governments (municipalities) use some beds in health care centres (which are
defined as hospitals) for providing some institution-based
long-term care (OECD, 2005).
76
The share of beds in private for-profit hospitals has
increased in some countries over the past decade. In
Germany, the share increased from 23% of all beds in 2002
to 30% in 2010, accompanied by a decrease in the share of
beds in public hospitals from 45% to 41%. The remaining
beds were in private not-for-profit hospitals (whose share
also declined slightly). In France, the share of beds in
private for-profit hospitals also increased during the past
decade but to a lesser extent, from 20% in 2000 to 23%
in 2010, while the proportion of beds in public hospitals
decreased from 66% in 2000 to 63% in 2010 (OECD, 2012a).
In several countries, the reduction in the overall
number of hospital beds has been accompanied by an
increase in their occupancy rates. Since 2000, the occupancy
rate of curative care beds increased significantly in Ireland
(from 85% in 2000 to 91% in 2010), Norway (from 85% to 93%)
and Switzerland (from 85% to 88%) (OECD, 2012a).
Hospital beds are defined as all beds that are regularly maintained and staffed and are immediately
available for use. They include beds in general hospitals, mental health and substance abuse hospitals,
and other specialty hospitals. Beds in nursing and
residential care facilities are excluded.
Curative care beds are beds accommodating patients
where the principal intent is to do one or more of the
following: cure physical illness or provide definitive
treatment of injury, perform surgery, relieve symptoms
of physical illness or injury (excluding palliative care),
reduce severity of physical illness or injury, protect
against exacerbation and/or complication of physical
illness and/or injury which could threaten life or
normal functions, perform diagnostic or therapeutic
procedures, manage labour (obstetric).
Psychiatric care beds are beds accommodating
patients with mental health problems. They include
beds in psychiatric departments of general hospitals,
and all beds in mental health and substance abuse
hospitals.
Long-term care beds are hospital beds accommodating patients requiring long-term care due to
chronic impairments and a reduced degree of independence in activities of daily living. They include
beds in long-term care departments of general
hospitals, beds for long-term care in specialty
hospitals, and beds for palliative care.
Data for some countries do not cover all hospitals.
In Ireland and the United Kingdom, data are
restricted to public or publicly-funded hospitals only.
3.5. HOSPITAL BEDS
3.5.1. Hospital beds per 1 000 population, 2010 and change between 2000 and 2010
Germany
Austria
Hungary
Czech Republic
Lithuania
Poland
Bulgaria
Belgium
France
Slovak Republic
Romania
Finland
Luxembourg
Estonia
Latvia
EU27
Greece
Netherlands
Slovenia
Malta
Cyprus
Italy
Denmark
Portugal
Spain
Ireland
United Kingdom
Sweden
8.3
7.6
7.2
7.0
6.8
6.6
6.5
6.4
6.4
6.4
6.3
5.9
5.4
5.3
5.3
5.3
4.9
4.7
4.6
4.5
3.7
3.5
3.5
3.4
3.2
3.1
3.0
2.7
5.6
5.4
5.0
4.6
3.9
3.3
2.5
6
-0.4
-1.4
-1.0
-2.7
n.a.
-1.3
n.a.
-2.1
-2.0
-2.0
-2.5
n.a.
-2.9
-4.8
-1.9
0.3
n.a.
-1.7
n.a.
-2.1
-2.9
-2.0
-1.1
-1.5
n.a.
n.a.
-2.0
Iceland
Croatia
Serbia
Switzerland
FYR of Macedonia
Montenegro
Norway
Turkey
5.8
10
8
-1.0
4
2
0
n.a.
-0.7
-1.4
-2.3
-1.0
-1.0
-3.3
2.3
-6
-3
0
3
1 2 http://dx.doi.org/10.1787/888932704380
3.5.2. Hospital beds by function of health care, 2010 (or nearest year)
Countries ranked from highest to lowest number of total hospital beds per capita
Curative care beds
%
100
Psychiatric care beds
Long-term care beds
Other hospital beds
80
60
96
93
40
72
69
69
58
78
74
66
74
64
84
78
69
65
54
63
69
81
66
80
82
82
78
80
73
74
63
60
63
69
72
20
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1 2 http://dx.doi.org/10.1787/888932704399
77
3.6. HOSPITAL DISCHARGES
Hospital discharges measure the number of people
who were released after staying at least one night in
hospital. Together with the average length of stay, they
are important indicators of hospital activities. Hospital
activities are affected by a number of factors, including the
capacity of hospitals to treat patients, the ability of the
primary care sector to prevent avoidable hospital admissions, and the availability of post-acute care settings to
provide rehabilitative and long-term care services.
In 2010, hospital discharge rates were the highest in
Austria, Bulgaria, Germany and Romania (Figure 3.6.1).
They were the lowest in Cyprus, Portugal and Spain as well
as in the Former Yugoslav Republic of Macedonia. In
general, countries that have a greater number of hospital
beds also tend to have higher discharge rates. For example,
the number of hospital beds per capita in Austria and
Germany is more than two-times greater than in Portugal
and Spain, and discharge rates are also more than twotimes greater (see Indicator 3.5).
Trends in hospital discharge rates over the past decade
vary widely across EU member states. In about one-third of
EU member states (including Austria, Bulgaria, Germany,
Greece, Poland and Romania), discharge rates have
increased between 2000 and 2010. In a second group of
countries (including the Czech Republic, Denmark,
Slovenia, Sweden and the United Kingdom), they have
remained stable, while in the third group (including
Finland, France, Hungary, Italy and Luxembourg), discharge
rates fell between 2000 and 2010.
Trends in hospital discharges may reflect several
factors that are not easily disentangled. Demand for hospitalisation may grow as populations age, given that older
people account for a disproportionately high percentage of
hospital discharges in all countries. For example, in Austria
and Germany, over 40% of all hospital discharges in 2010
were for people aged 65 and over, more than twice their
share of the population (17.6% and 20.7% respectively).
However, population ageing alone may be a less important
factor in explaining trends in hospitalisation rates than
changes in medical technologies and clinical practices. A
significant body of research shows that the diffusion of
new medical interventions gradually extends to older
population groups, as interventions become safer and
more effective for people at older ages (e.g. Dormont and
Huber, 2006). However, the diffusion of new medical technologies may also involve a reduction in hospitalisation if it
entails a shift from procedures requiring overnight stays in
hospitals to same-day procedures. In the group of countries
78
where discharge rates have decreased over the past decade,
the reduction can be explained at least partly by a strong
rise in the number of day surgeries (see Indicator 3.9, for
example, for evidence on the rise in day surgeries for
cataracts).
Lithuania has the highest discharge rate for circulatory
diseases, followed by Bulgaria and Germany (Figure 3.6.2).
The high rates in Bulgaria and Lithuania are associated with
high mortality rates from circulatory diseases, which may be
used as a proxy indicator for the occurrence of these
diseases (see Indicator 1.4). But Germany does not have high
mortality rates for circulatory diseases, suggesting that
different clinical practices may play a role in explaining high
discharge rates.
Austria and Germany have the highest discharge rates
for cancer, followed by Hungary (Figure 3.6.3). While the
high rate in Hungary is associated with a high mortality rate
from cancer (which may also be used as a proxy for the
occurrence of the disease; see Indicator 1.5), this is not the
case for Austria and Germany. In Austria, the high rate is
associated with a high rate of hospital readmissions for further investigation and treatment of cancer patients (EC,
2008a).
Discharge is defined as the release of a patient who
has stayed at least one night in hospital. It includes
deaths in hospital following inpatient care. Same-day
separations are usually excluded, with the exception
of Norway, Poland, the Slovak Republic and Turkey
which include some same-day separations.
Healthy babies born in hospitals are excluded
completely (or almost completely) from hospital discharge rates in several countries (e.g. Austria, Cyprus,
Estonia, Finland, Greece, Ireland, Latvia, Luxembourg,
Spain, Turkey). These comprise 3-7% of all discharges.
Data for some countries do not cover all hospitals. In
Denmark, Ireland and the United Kingdom, data are
restricted to public or publicly-funded hospitals only.
Data for Portugal relate only to public hospitals on the
mainland. Data for Austria, Estonia, Luxembourg and
the Netherlands include only acute care/short-stay
hospitals.
3.6. HOSPITAL DISCHARGES
3.6.1. Hospital discharges per 1 000 population, 2000 and 2010 (or nearest year)
2000
2010
141
129
158
142
172
169
175
99
102
116
112
132
128
136
132
149
144
163
150
156
169
169
172
178
176
185
182
195
200
192
212
203
237
224
240
261
250
254
300
80
100
50
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1. Excludes discharges of healthy babies born in hospital (between 3-7% of all discharges).
2. Includes same-day discharges.
1 2 http://dx.doi.org/10.1787/888932704418
3.6.2. Hospital discharges for circulatory diseases
per 1 000 population, 2010 (or nearest year)
Lithuania
Bulgaria
Germany
Romania
Slovak Republic
Austria
Estonia
Hungary
Poland
Greece
Finland
Latvia
Czech Republic
EU27
Sweden
Belgium
Slovenia
Italy
Denmark
Luxembourg
France
Netherlands
Malta
Portugal
Spain
United Kingdom
Ireland
Cyprus
3.6.3. Hospital discharges for cancers
45
38
36
33
33
33
32
30
29
28
27
27
27
24
23
21
20
20
20
20
19
17
13
13
13
13
12
8
Norway
Croatia
Switzerland
Turkey
FYR of Macedonia
Iceland
19
15
14
14
15
30
45
1 2 http://dx.doi.org/10.1787/888932704437
29
25
23
20
20
19
18
17
17
17
17
16
15
15
14
14
13
13
12
12
12
11
11
10
9
8
8
5
Croatia
Norway
Switzerland
Iceland
FYR of Macedonia
Turkey
24
20
0
Austria
Germany
Hungary
Romania
Greece
Slovak Republic
Poland
Slovenia
Lithuania
Finland
Estonia
Bulgaria
Czech Republic
EU27
Luxembourg
Denmark
Latvia
Sweden
Italy
Belgium
France
Portugal
Netherlands
Spain
United Kingdom
Malta
Ireland
Cyprus
19
16
14
12
12
9
0
10
20
30
1 2 http://dx.doi.org/10.1787/888932704456
79
3.7. AVERAGE LENGTH OF STAY IN HOSPITALS
The average length of stay in hospitals is often regarded
as an indicator of efficiency, since a shorter stay may reduce
the cost per discharge and shift care from inpatient to less
expensive post-acute settings. However, shorter stays tend
to be more service intensive and more costly per day.
Too short a length of stay could also have adverse effects on
health outcomes, or reduce the comfort and recovery of the
patient. If this leads to a rising readmission rate, costs per
episode of illness may fall little, or even rise.
In 2010, the average length of stay in hospitals was the
lowest in Turkey, Norway and Denmark (Figure 3.7.1). It
was the highest in Finland, followed by the Former Yugoslav
Republic of Macedonia, Croatia, Switzerland and Germany.
The high average length of stay in Finland is due to a large
proportion of beds allocated for convalescent patients and
long-term care (see Indicator 3.5). Focusing only on stays in
acute care units, the average length of stay in Finland is not
greater, indeed is even lower than in most other European
countries.
The average length of stay in hospitals has decreased
over the past decade in all European countries, falling from
8.2 days in 2000 to 6.9 days in 2010 on average in EU member
states (Figure 3.7.1). The reduction in average length of stay
was particularly marked in Bulgaria, Croatia, the Former
Yugoslav Republic of Macedonia and Switzerland. It also
decreased in the Netherlands and the United Kingdom.
Several factors explain this general decline, including the
use of less invasive surgical procedures, changes in hospital
payment methods, and the expansion of early discharge
programmes enabling patients to return to their home to
receive follow-up care.
A growing number of countries (e.g. France, Germany,
Poland) have moved to prospective payment methods often
based on diagnosis-related groups (DRGs) to set payments
based on the estimated cost of hospital care for different
patient groups in advance of service provision. These
payment methods have the advantage of encouraging
providers to reduce the cost of each episode of care (OECD,
2010b). In Switzerland, the move from per diem payments to
diagnosis-related groups (DRG) based payments has contributed to the reduction in length of stay in those cantons that
have modified their payment system (OECD and WHO, 2011).
In the Netherlands, the introduction of a new payment
system for hospitals in 2006 also provided incentives to
reduce length of stay. Prior to the reform, hospitals were paid
80
on a fixed amount per bed and beddays. Since 2006, a
growing share of hospital payments is determined through
negotiations between insurers and hospitals, based on the
Dutch version of DRGs (Westert and Klazinga, 2011). While
the average length of stay in hospitals in the Netherlands
used to be above the EU average in 2000, it has now fallen
below. Still, a number of additional interventions have been
identified by hospital staff to further reduce length of stay in
Dutch hospitals, including a further increase in the share of
same-day surgery, reducing waiting times for examinations,
implementing acute stroke units, and promoting early
discharge planning and follow-up (Borghans et al., 2012).
Focusing on average length of stay for specific diseases
or conditions can remove some of the heterogeneity that
may arise from the different mix and severity of conditions
across countries. Figure 3.7.2 shows that the average length
of stay for a normal delivery ranges from less than two days
in Turkey, Iceland, the United Kingdom and the Netherlands,
to five days or more in the Slovak Republic, Romania, Croatia
and Switzerland. The length of stay for a normal delivery
has become shorter in nearly all countries over the past
decade, dropping from five days in 2000 to about three-anda-half days in 2010 on average in EU member states.
Lengths of stay following acute myocardial infarction
(AMI, or heart attack) also declined over the past ten years.
In 2010, it was the lowest in Denmark, Norway and Turkey,
at four days or less. At the other end of the scale, it was
highest in Estonia, Germany, Lithuania and Croatia, at over
nine days (Figure 3.7.3). In this latter group of countries,
long average length of stays may be due to the fact that
some patients originally admitted for AMI are no longer
receiving acute care, but nonetheless stay in hospitals for a
certain period to receive post-acute care.
Average length of stay (ALOS) refers to the average
number of days that patients spend in hospital. It is
generally measured by dividing the total number of
days stayed by all inpatients during a year by the
number of admissions or discharges. Day cases are
excluded.
3.7. AVERAGE LENGTH OF STAY IN HOSPITALS
3.7.1. Average length of stay in hospital for all causes, 2000 and 2010 (or nearest year)
2000
9.6
5.8
8.1
9.0
9.9
9.8
4.1
4.5
4.6
5.7
5.1
5.7
5.8
5.7
6.0
5.9
6.1
6.1
6.6
6
6.3
6.8
6.8
6.7
7.0
6.9
7.0
7.3
7.1
7.5
7.5
7.9
7.7
8.1
9
8.0
9.5
12
2010
11.6
Days
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1 2 http://dx.doi.org/10.1787/888932704475
3.7.2. Average length of stay for normal delivery,
Slovak Republic
Romania
Cyprus
Czech Republic
Hungary
Belgium
France
Bulgaria
Luxembourg
Austria
Greece
Poland
Slovenia
Latvia
Lithuania
EU26
Italy
Finland
Germany
Denmark
Portugal
Malta
Spain
Sweden
Ireland
Netherlands
United Kingdom
3.7.3. Average length of stay for acute myocardial
infarction (AMI), 2010 (or nearest year)
5.3
5.0
4.6
4.6
4.5
4.3
4.3
4.2
4.1
4.0
4.0
4.0
4.0
3.7
3.7
3.6
3.5
3.1
3.1
2.7
2.7
2.7
2.5
2.3
2.0
1.9
1.8
Croatia
Switzerland
FYR of Macedonia
Norway
Iceland
Turkey
5.4
5.0
4.7
3.1
1.8
1.5
0
2
4
6
Days
1 2 http://dx.doi.org/10.1787/888932704494
Germany
Lithuania
Estonia
Finland
Ireland
Portugal
Romania
Spain
United Kingdom
Italy
Slovenia
Belgium
Malta
Austria
Latvia
EU27
Cyprus
Greece
Netherlands
Czech Republic
France
Hungary
Luxembourg
Poland
Bulgaria
Sweden
Slovak Republic
Denmark
10.6
9.4
9.1
8.1
8.0
7.9
7.9
7.8
7.8
7.7
7.7
7.6
7.6
7.2
7.1
7.1
7.1
7.0
6.5
6.4
6.2
5.9
5.9
5.7
5.1
4.7
4.6
3.9
Croatia
Switzerland
FYR of Macedonia
Iceland
Norway
Turkey
10.2
7.9
7.1
6.8
4.0
4.0
0
4
8
12
Days
1 2 http://dx.doi.org/10.1787/888932704513
81
3.8. CARDIAC PROCEDURES (CORONARY ANGIOPLASTY)
Heart diseases are a leading cause of hospitalisation
and death in European countries (see Indicator 1.4). Coronary angioplasty is a procedure that has revolutionised the
treatment of ischemic heart diseases over the past twenty
years, involving the use of a minimally invasive technique to
re-open the obstructed coronary arteries rather than an
open-chest bypass surgery. The placement of a stent to keep
the artery open accompanies the majority of angioplasties.
There is considerable variation across European
countries in the use of coronary angioplasty (Figure 3.8.1).
Germany, Belgium and Austria had the highest rates of
angioplasty in 2010, although the rates in these three
countries are overestimated because they are based on a
count of all procedures rather than based on a count of
patients (see the box on “Definition and comparability”).
The angioplasty rate was the lowest in Ireland, Poland,
Romania and the United Kingdom. However, in these latter
two countries, the data do not cover activities in private
hospitals, resulting in some underestimation.
The use of angioplasty has increased rapidly since 1990
in most European countries, overtaking coronary bypass
surgery as the preferred method of revascularisation around
the mid-1990s – about the same time that the first published
trials of the efficacy of coronary stenting began to appear
(Moïse, 2003). In most European countries, angioplasty
now accounts for at least 70% of all revascularisations
(Figure 3.8.2). The EU average is close to 80%. For a large
number of EU countries, the growth in angioplasty was
higher between 2000 and 2005, compared to the 2005-10
period. Countries such as Romania, Spain and Sweden,
which had low rates of angioplasty in 2000, have witnessed
high annual growth rates since then. Whilst variation in the
use of angioplasty persists, the degree of variation has
diminished over the past decade, as many countries have
caught up with the early adopters of this technology.
Coronary angioplasty has expanded surgical treatment
options to wider sections of the patient population, although
a UK study found that approximately 30% of all angioplasty
procedures are a direct substitute for bypass surgery
(McGuire et al., 2010). Angioplasty is however not a perfect
substitute since bypass surgery is still the preferred method
82
for treating patients with multiple-vessel obstructions,
diabetes and other conditions (Taggart, 2009).
Coronary angioplasty is an expensive intervention,
but it is much less costly than a coronary bypass surgery
because it is less invasive. The estimated price of an angioplasty on average across European countries was about
EUR 5 900 in 2009 compared with EUR 15 300 for a coronary
bypass. Hence, for patients who would otherwise have
received bypass surgery, the introduction of angioplasty
has not only improved outcomes but has also decreased
costs. However, because of the expansion of surgical interventions, overall costs have risen.
A number of reasons can explain cross-country variations in the rate of angioplasty, including: i) differences in
the incidence and prevalence of ischemic heart diseases;
ii) differences in the capacity to deliver and pay for these
procedures; iii) differences in clinical treatment guidelines
and practices; and iv) differences in coding and reporting
practices.
The data relate to inpatient procedures, excluding
coronary angioplasties performed or recorded as day
cases. In most countries, the data refer to the number
of patients who have received an angioplasty during a
hospital stay, except in Austria, Belgium, Germany
and Slovenia where they are based on a count of all
procedures (including possibly several procedures per
patient), leading to an overestimation compared with
other countries.
In Ireland and the United Kingdom, the data only
include activities in publicly-funded hospitals, resulting in an underestimation (it is estimated that over
10% of all hospital activity in Ireland is undertaken in
private hospitals). Data for Portugal relate only to
public hospitals on the mainland.
3.8. CARDIAC PROCEDURES (CORONARY ANGIOPLASTY)
3.8.1. Coronary angioplasty per 100 000 population, 2010 and change between 2000 and 2010
Germany
624
4.2
Belgium
469
197
France
197
Luxembourg
193
Slovenia
191
EU21
n.a.
3.3
4.2
20.4
9.4
182
Estonia
180
Sweden
177
Greece
n.a.
13.4
n.a.
172
Hungary
170
Netherlands
8.0
6.8
Denmark
158
136
Spain
132
Finland
4.0
12.4
7.1
Italy
131
4.5
Portugal
118
11.2
94
United Kingdom
90
Ireland
87
Poland
n.a.
6.9
8.9
Romania
53
29.2
Norway
238
8.2
Iceland
198
2.3
Switzerland
164
400
8.6
Czech Republic
205
800
600
7.6
Austria
240
200
9.8
0
0
10
20
30
Note: Some of the variations across countries are due to different classification systems and recording practices.
1 2 http://dx.doi.org/10.1787/888932704532
3.8.2. Coronary angioplasty as a share of total revascularisation procedures, 2000 and 2010 (or nearest year)
2000
2010
% of total revascularisation procedures
100
89
87
85
84
81
78
80
81
81
79
79
79
78
75
75
71
68
73
70
68
64
66
68
67
64
61
66
61
57
60
77
75
55
47
42
41
40
20
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Fr
Sp
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Note: Revascularisation procedures include coronary bypass and angioplasty.
1 2 http://dx.doi.org/10.1787/888932704551
83
3.9. CATARACT SURGERIES
In the past two decades, the number of surgical procedures carried out on a same-day basis, without any need
for hospitalisation, has grown in European countries.
Advances in medical technologies, particularly the diffusion of less invasive surgical interventions, and better
anaesthetics have made this development possible. These
innovations have also improved patient safety and health
outcomes for patients, and have in many cases reduced the
unit cost per intervention by shortening the length of stay
in hospitals. However, the impact of the rise in same-day
surgeries on health spending depends not only on changes
in their unit cost, but also on the growth in the volume of
procedures performed. There is also a need to take into
account any additional cost related to post-acute care and
community health services following the intervention.
Cataract surgery provides a good example of a high
volume surgery which is now carried out predominantly on
a same-day basis in most European countries. The operation
began to change from an inpatient to a same-day surgery in
the 1980s in some countries such as Sweden (Henning et al.,
1985), with the movement then spreading to other European
countries at different speed. From a medical point of view,
a cataract surgery using modern techniques should not
normally require an hospitalisation. However, in some
specific cases (e.g. general anesthesia or severe comorbidities), a hospital stay may be required (Lundström et al., 2012).
Day surgery now accounts for over 90% of all cataract
surgeries in many countries (Figure 3.9.1). However, the use
of day surgery is still relatively low in some countries, such
as Lithuania, Poland and the Slovak Republic. This may
be explained by more advantageous reimbursement for
inpatient stays, national regulations, obstacles to changing
individual practices of surgeons and anaesthetists, and
tradition (Castoro et al., 2007). These low rates may also
reflect limitations in data coverage of outpatient activities
in hospitals or outside hospitals.
The number of cataract surgeries performed on a sameday basis has grown very rapidly in some countries over the
past ten years, such as in Austria and Portugal (Figure 3.9.2),
catching up to the high rates already observed in 2000 in
Nordic countries, the Netherlands and Spain. In Portugal,
the strong rise in the number of cataract surgeries
performed as day cases rather than as inpatients has led to
a sharp increase in the share of same-day surgery, rising
from less than 10% in 2000 to over 90% in 2010 (Figure 3.9.1).
In France, this share also increased from 32% in 2000 to 80%
in 2010. In Luxembourg, the number of cataract surgeries
carried out as day cases and outpatient cases (in or outside
hospitals) has also risen rapidly, although they still account
for only about half of all cataract surgeries.
84
Cataract surgery has now become the most frequent
surgical procedure in many European countries. The operation is performed more often in women than men (around
60% vs. 40%), because it is related to age and women live
longer (Lundström et al., 2012). While population ageing is
one of the factors behind the rise in cataract surgery, the
proven success, safety and cost-effectiveness of the operation as a day procedure has been a more important factor
(Fedorowicz et al., 2004).
In Sweden, there is evidence that cataract surgeries
are now being performed on patients suffering from less
severe vision problems compared to ten years ago. This
raises the issue of how the needs of these patients should
be prioritised relative to other patient groups (Swedish
Association of Local Authorities and Regions and National
Board of Health and Welfare, 2010). The European Registry
of Quality Outcomes for Cataract and Refractive Surgery
recently developed evidence-based guidelines to improve
treatment and standards of care for cataract surgery
(Lundström et al., 2012).
Cataract surgeries consist of removing the lens of the
eye because of the presence of cataracts which are
partially or completely clouding the lens, and replacing
it with an artificial lens. The surgery may involve in
certain cases an overnight stay in hospital (inpatient
cases), but in many countries it is now performed
mainly as day cases (defined as a patient admitted to
the hospital and discharged the same day) or outpatient
cases in hospitals or outside hospitals (without any
formal admission and discharge). However, the data for
many countries do not include such outpatient cases in
hospitals or outside hospitals, with the exception of the
Czech Republic, France, Hungary and Luxembourg
where they are included. Caution is therefore required
in making cross-country comparisons of available data,
given the incomplete coverage of same-day surgeries in
several countries.
In Denmark, Ireland, the Netherlands and the
United Kingdom, the data only include cataract
surgeries carried out in public hospitals, excluding
any procedures performed in private hospitals and in
the ambulatory sector (in Ireland, it is estimated that
over 10% of all hospital activity is undertaken in
private hospitals). The data for Spain only partially
include activities in private hospitals.
3.9. CATARACT SURGERIES
3.9.1. Share of cataract surgeries carried out as day cases, 2000 and 2010 (or nearest year)
2000
79.6
79.0
93.6
87.3
96.8
71.6
80.1
85.4
71.2
80
89.1
90.4
2010
91.9
93.4
85.9
95.9
92.8
97.4
98.1
83.1
98.2
82.8
98.7
82.0
99.0
99.6
%
100
48.9
7.9
1.0
n.a.
3.8
1.2
0.1
n.a.
n.a.
n.a.
9.3
20
16.8
17.4
28.4
32.8
38.6
42.9
31.6
37.6
32.0
40
52.7
60
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1. Data for the Czech Republic, France, Luxembourg and Hungary include outpatient cases in hospitals and outside hospitals.
1 2 http://dx.doi.org/10.1787/888932704570
3.9.2. Growth in cataract surgeries per capita, day cases and inpatient cases, 2000 to 2010 (or nearest year)
Day cases
Inpatient cases
54.1
45.9
60
4.9
4.3
0.4
7.2
7.3
7.4
8.5
9.1
5.4
1.1
5.2
9.3
10.8
13.6
20
11.5
33.4
40
0.0
-2.6
-15.3
-22.0
-14.8
-5.2
-23.0
-26.7
-20.6
-15.7
-13.2
-17.9
-20
-12.2
-8.6
-8.5
-2.1
0
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1 2 http://dx.doi.org/10.1787/888932704589
85
3.10. HIP AND KNEE REPLACEMENT
Significant advancements in surgical treatment have
provided effective options to reduce the pain and disability
associated with certain musculoskeletal conditions. Joint
replacement surgery (hip and knee replacement) is considered the most effective intervention for severe osteoarthritis, reducing pain and disability and restoring some
patients to near normal function.
the knee replacement rate more than tripled. Similarly, in
Spain, the hip replacement rate increased by 25% and the
knee replacement rate more than doubled during the past
decade. The growth rate for both interventions was somewhat slower in France, but still the hip replacement rate
increased by nearly 10% while the knee replacement rate
rose by 60% between 2000 and 2010.
Ostheoarthritis is one of the ten most disabling
diseases in developed countries. Worldwide estimates are
that 9.6% of men and 18.0% of women aged over 60 years
have symptomatic osteoarthritis, including moderate and
severe forms (WHO, 2010a). Age is the strongest predictor
of the development and progression of osteoarthritis. It is
more common in women, increasing after the age of 50
especially in the hand and knee. Other risk factors include
obesity, physical inactivity, smoking, excess alcohol and
injuries (EC, 2008b). While joint replacement surgery is
mainly carried out among people aged 60 and over, it can
also be performed among people at younger ages.
The growing volume of hip and knee replacement is
contributing to health expenditure growth since these are
expensive interventions. In 2009, the estimated price of a
hip replacement on average across European countries was
about EUR 7 300, while the price of a knee replacement was
EUR 6 800.
Austria, Belgium, Germany and Switzerland have
the highest rates of hip replacement (Figure 3.10.1). These
countries also have the highest rates of knee replacement,
along with Finland (Figure 3.10.2). Differences in population
structure may explain part of these variations across
countries, and age-standardisation reduces to some extent
the variations across countries. But still, large differences
remain and the country ranking does not change significantly
after age standardisation (McPherson et al., 2012). Beyond
different population structures, a number of other reasons
may explain cross-country variations in the rate of hip and
knee replacement: i) differences in the prevalence of osteoarthritis problems; ii) differences in the capacity to deliver
and pay for these expensive procedures; and iii) differences in
clinical treatment guidelines and practices.
The rate of hip and knee replacement has increased
over the past ten years in many European countries, due in
part to population ageing but also the growing use of these
interventions to improve functioning among elderly people
(Figures 3.10.3 and 3.10.4). In Denmark, the hip replacement rate increased by 40% between 2000 and 2010, while
86
Hip replacement is a surgical procedure in which
the hip joint is replaced by a prosthetic implant. It is
generally conducted to relieve arthritis pain or treat
severe physical joint damage following hip fracture.
Knee replacement is a surgical procedure to replace
the weight-bearing surfaces of the knee joint to
relieve the pain and disability of osteoarthritis. It
may be performed for other knee diseases such as
rheumatoid arthritis.
Classification systems and registration practices
vary across countries which may affect the comparability of the data. Some countries only include total
hip replacement (e.g. Estonia) while most also include
partial replacement. Certain countries only include
initial knee replacement while others also include
revisions.
In Ireland, the data only include activities in
publicly-funded hospitals (it is estimated that over
10% of all hospital activity is undertaken in private
hospitals).
3.10. HIP AND KNEE REPLACEMENT
3.10.1. Hip replacement surgery,
3.10.2. Knee replacement surgery,
Germany
Germany
295
Austria
249
Belgium
245
Denmark
France
225
Sweden
210
208
Finland
Denmark
163
Slovenia
Sweden
125
France
124
112
EU21
109
153
Italy
128
Czech Republic
159
EU24
142
Netherlands
170
Czech Republic
175
155
United Kingdom
181
Greece
178
Luxembourg
199
United Kingdom
187
Belgium
213
Luxembourg
201
Finland
225
Netherlands
213
Austria
Spain
104
147
Ireland
Italy
122
Hungary
Slovenia
99
Spain
Latvia
89
Cyprus
Portugal
88
Hungary
Estonia
85
Poland
53
45
44
Latvia
63
41
Poland
48
Cyprus
62
Ireland
74
Romania
86
Portugal
97
Slovak Republic
98
15
Romania
10
15
Switzerland
Switzerland
266
Norway
242
Iceland
100
132
Norway
173
0
212
Iceland
200
300
84
0
100
200
300
1 2 http://dx.doi.org/10.1787/888932704608
1 2 http://dx.doi.org/10.1787/888932704627
3.10.3. Trend in hip replacement surgery,
2000-10, selected countries
3.10.4. Trend in knee replacement surgery,
2000-10, selected countries
Denmark
France
Germany
Austria
Denmark
France
Poland
Spain
EU24
Germany
Ireland
EU21
10
20
09
20
08
20
07
20
06
20
05
20
04
20
03
20
02
20
20
20
20
20
20
20
20
20
20
20
20
20
1 2 http://dx.doi.org/10.1787/888932704646
00
0
10
0
09
50
08
50
07
100
06
100
05
150
04
150
03
200
02
200
01
250
00
250
20
300
01
300
1 2 http://dx.doi.org/10.1787/888932704665
87
3.11. PHARMACEUTICAL CONSUMPTION
The consumption of pharmaceuticals has increased
over the past decade not only in terms of expenditure (see
Indicator 5.5 “Pharmaceutical expenditure”), but also in
terms of the volume or quantity of medicines consumed.
This section reviews trends in the volume of consumption of
three categories of pharmaceuticals: antibiotics, antidiabetics and antidepressants. Consumption of these medicines is
measured through the defined daily dose (DDD) unit, as
recommended by the WHO Collaborating Center for Drug
Statistics (see the box on “Definition and comparability”).
Antibiotics should not be used needlessly, as there is a
clear correlation between their use and the emergence of
resistant bacterial strains (Bronzwaer et al., 2002; Goossens
et al., 2005). As with any other prescribed medicines, overprescribing exposes patients unnecessarily to risks of
side-effects without achieving more rapid recovery (Fahey
et al., 2004).
The use of antibiotics varies across European countries,
ranging from 10 DDDs per 1 000 people per day in Latvia, the
Netherlands and Romania, to over 30 in Greece and Cyprus
(Figure 3.11.1). Consumption has stabilised in several
countries over the past decade, and it has decreased in some
countries including Estonia, France, Hungary, Portugal and
Slovenia. But antibiotic use has risen in other countries such
as Belgium, Greece and Italy which already had higher-thanaverage consumption in 2000, thereby widening the gap with
other European countries. One way of reducing unnecessary
use is to avoid prescribing them for mild and/or viral infections. Many countries have launched information campaigns
targeting physicians and patients to reduce consumption. At
the international level, WHO launched in 2011 a campaign to
stimulate co-ordinated efforts to promote appropriate and
rational use of antibiotics (WHO, 2012b).
Clinical guidelines in different European countries
recommend the use of various medicines to treat people
with diabetes to reduce the risk of cardiovascular and microvascular complications (Beckman et al., 2002; UKPDS, 1998).
There is wide variation in the use of medicines for the
treatment of diabetes across European countries, with
consumption in Iceland and Estonia almost half that in
Finland or Germany (Figure 3.11.2). This can be partly
explained by the prevalence of diabetes, which is low in
Iceland (see Indicator 1.10). However, some of the countries
with the highest consumption do not have high diabetes
prevalence (e.g. Finland, Germany and the United Kingdom).
Between 2000 and 2010, the consumption of antidiabetics
increased by 75% on average across EU member states. The
growth rate was particularly strong in Finland, Germany and
the Slovak Republic. The main reasons for this strong rise
are increases in the proportion of people treated and the
average dosages used in treatments (Melander et al., 2006).
88
Guidelines for the pharmaceutical treatment of
depression vary across countries, and there is also great
variation in prescribing behaviors among general practitioners and psychiatrists not only across countries, but also
among individual practitioners in each country. Iceland
has the highest level of consumption of antidepressants,
followed by Denmark and Portugal (Figure 3.11.3). Part of
the explanation for the high consumption in Iceland is that
a much higher proportion of the population receives at
least one prescription for an antidepressant each year.
In 2008, almost 30% of women aged 65 and over had an
antidepressant prescription in Iceland, compared with less
than 15% in Norway (NOMESCO, 2010). But the intensity
and duration of treatments also play a role in explaining
variations across countries and trends over time. In all
European countries for which data is available, the
consumption of antidepressants has increased a lot over
the past decade, by over 80% on average across EU member
states. While some analysts interpret these findings as
evidence of a growing prevalence of depression, this also
reflects greater efforts to provide treatments to people
suffering from severe depression and greater intensity of
these treatments. This rise can also be explained by the
extension of the set of indications of some antidepressants
to milder forms of depression, generalised anxiety disorders or social phobia, which have raised issues in some
countries about the appropriateness of such extensions of
prescriptions.
Defined daily dose (DDD) is the assumed average
maintenance dose per day for a medicine used for its
main indication in adults. DDDs are assigned to each
active ingredient(s) in a given therapeutic class by
international expert consensus. For instance, the
DDD for oral aspirin equals 3 grams, which is the
assumed maintenance daily dose to treat pain in
adults. DDDs do not necessarily reflect the average
daily dose actually used in a given country. DDDs can
be aggregated within and across therapeutic classes
of the Anatomic-Therapeutic Classification (ATC). For
more detail, see www.whocc.no/atcddd.
Data generally refer to outpatient consumption
except for the Czech Republic, Finland and Sweden,
where data also include hospital consumption. Greek
figures may include parallel exports.
3.11. PHARMACEUTICAL CONSUMPTION
3.11.1. Antibiotics consumption, 2000 and 2010 (or nearest year)
2000
2010
Defined daily dose, per 1 000 people per day
45
40
39
34
35
30
25
20
15
15
10
10
10
10
22
21
16
16
15
14
13
13
20
20
19
19
19
18
18
30
25
24
23
22
21
20
30
28
28
5
d
Ic
el
an
tia
ay
Cr
No
oa
rw
ce
us
Gr
ee
ly
Fr
Cy
pr
It a
m
an
ce
g
iu
lg
Be
ic
ur
bl
bo
pu
m
Re
xe
Sl
Lu
l
la
Po
ak
ov
ec
Cz
i te
Un
nd
ta
ga
Po
r tu
nd
al
la
M
Ir e
n
23
ai
Sp
EU
a
ic
ni
Li
th
ua
k
bl
ar
h
De
pu
nm
lg
Bu
Re
ar
d
ia
m
an
nl
Fi
ria
do
st
ng
d
Au
Ki
y
en
Sw
ed
y
ar
ng
Hu
an
ia
Ge
rm
a
ni
en
to
ov
Es
Sl
s
La
tv
ia
nd
an
la
m
er
th
Ne
Ro
ia
0
Source: OECD Health Data 2012; European Surveillance of Antimicrobial Consumption (ESAC) project, 2011.
1 2 http://dx.doi.org/10.1787/888932704684
3.11.2. Antidiabetics consumption,
2000 and 2010 (or nearest year)
2000
Estonia
2010
Estonia
Spain
Belgium
Slovak Republic
Luxembourg
Portugal
France
55
40
56
Netherlands
41
56
Czech Republic
Slovenia
44
58
Luxembourg
45
Germany
62
France
63
EU18
74
United Kingdom
81
Finland
83
Iceland
48
0
25
50
75
100
1 2 http://dx.doi.org/10.1787/888932704703
61
66
Belgium
69
Finland
69
76
Portugal
79
Denmark
84
Norway
32
Norway
52
Sweden
75
Germany
50
United Kingdom
71
Czech Republic
47
Spain
68
Hungary
42
57
66
Netherlands
29
Italy
59
EU15
26
Slovak Republic
51
2010
16
Hungary
48
Sweden
Slovenia
2000
45
Denmark
Italy
3.11.3. Antidepressants consumption,
2000 and 2010 (or nearest year)
56
Iceland
101
0
30
60
90
120
1 2 http://dx.doi.org/10.1787/888932704722
89
3.12. UNMET HEALTH CARE NEEDS
All European countries endorse equity of access to
health care for all people as an important policy objective.
One method of gauging to what extent this objective is
achieved is through assessing reports of unmet needs for
health care. The problems that people report in obtaining
care when they are ill or injured often reflect significant
barriers to care.
Some common reasons given for not receiving care
include excessive treatment costs, long waiting times, not
being able to take time off work or needing to look after
children, or having to travel too far to receive care. Differences
in the reporting of unmet care needs across countries may be
due partly to socio-cultural differences. However, these
factors play a lesser role in explaining any differences among
population groups within each country. It is also important to
consider self-reported unmet care needs in conjunction with
other indicators of potential barriers to access, such as the
extent of health insurance coverage and the amount of
out-of-pocket payments (see Indicators 5.1 “Coverage for
health care” and 5.6 “Financing of health care”).
In all European countries, a majority of the population
reported no unmet care needs, according to the 2010
EU Statistics on Income and Living Conditions survey
(EU-SILC). However, in some countries, significant proportions of people reported having unmet needs. In Bulgaria,
Croatia, Latvia, Poland, Romania and Sweden, more than
10% of survey respondents had an unmet need for a
medical examination, and the burden fell heaviest on low
income earners, particularly in Bulgaria and Latvia
(Figure 3.12.1). On average across EU member states, twice
as many low income earners reported unmet needs as did
high income earners, indicating that affordability remains
an important issue for some population groups.
The most common reason for not obtaining care was
because of treatment costs, and this was particularly the
case in Latvia and Romania. Waiting times were an issue
for some people in Bulgaria, Estonia, Finland and Poland.
Generally, women tend to report slightly more unmet
health care needs than men. Aside from people in lowincome groups, those who are unemployed or less
90
educated are also more likely to report unmet needs
(Figure 3.12.3).
A larger proportion of the population indicates unmet
needs for dental care than for medical care. Often, dental
care is only partially included, or not included at all in
basic health care coverage, and so must either be paid
out-of-pocket, or covered through purchasing private health
insurance. Latvia (21.5%) reported the highest rates of unmet
need for a dental examination in 2010, followed by Bulgaria,
Portugal, Romania, Cyprus, Iceland, Italy and Poland (all
between 10-15%) (Figure 3.12.2). Large inequalities in unmet
dental care needs were evident between high and low
income groups in most of these countries. The population in
Belgium, the Netherlands, Slovenia and the United Kingdom
reported the lowest rates of unmet dental care needs in 2010
(between 1% and 3% only), according to EU-SILC.
Questions on unmet health care needs are a feature
of a number of national and cross-national health
interview surveys, including the European Union
Statistics on Income and Living Conditions survey
(EU-SILC). To determine unmet medical and dental
care, individuals are asked in EU-SILC whether there
was a time in the previous 12 months when they felt
they needed health care or dental care services but
did not receive them, followed by a question as to why
the need for care was unmet. Common reasons given
include that care was too expensive, the waiting time
was too long, or wanting to wait to see if the problem
would get better.
Cultural factors and policy debates may affect
responses to questions about unmet care. Caution is
therefore needed in comparing the magnitude of
inequalities across countries.
3.12. UNMET HEALTH CARE NEEDS
3.12.1. Unmet need for a medical examination,
by income quintile, 2010
High income
Average
3.12.2. Unmet need for a dental examination,
by income quintile, 2010
Low income
High income
Latvia
Bulgaria
Poland
Romania
Sweden
Hungary
Greece
Italy
Spain
Cyprus
EU27
Germany
Estonia
Malta
Finland
Slovak Republic
France
Denmark
United Kingdom
Czech Republic
Luxembourg
Lithuania
Ireland
Portugal
Austria
Netherlands
Belgium
Slovenia
Latvia
Bulgaria
Portugal
Romania
Cyprus
Italy
Poland
Spain
Sweden
France
Greece
EU27
Estonia
Finland
Hungary
Austria
Ireland
Czech Republic
Slovak Republic
Malta
Germany
Denmark
Lithuania
Luxembourg
United Kingdom
Belgium
Netherlands
Slovenia
Croatia
Iceland
Norway
Switzerland
Iceland
Croatia
Norway
Switzerland
0
10
20
30
40
%
0
Source: Eurostat Statistics Database, based on EU-SILC.
1 2 http://dx.doi.org/10.1787/888932704741
Average
10
Low income
20
30
40
%
1 2 http://dx.doi.org/10.1787/888932704760
3.12.3. Inequalities in unmet need for a medical examination, EU27 average, 2010
%
12
Gender
Age group
Income
Education level
10
Activity status
9.3
9.2
8.0
8
7.4
7.3
7.0
6.7
7.5
7.2
6.9
7.0
7.0
6.3
6.0
5.9
6
5.5
5.7
5.4
4.8
4.3
4
3.5
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24
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25
18
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1 2 http://dx.doi.org/10.1787/888932704779
91
© OECD 2012
Chapter 4
Quality of care
Care for chronic conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
94
4.1.
Avoidable admissions: Respiratory diseases. . . . . . . . . . . . . . . . . . . . .
94
4.2.
Avoidable admissions: Uncontrolled diabetes . . . . . . . . . . . . . . . . . . .
96
Acute care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
98
4.3.
In-hospital mortality following acute myocardial infarction . . . . . . .
98
4.4.
In-hospital mortality following stroke . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.5.
Procedural or postoperative complications. . . . . . . . . . . . . . . . . . . . . . 102
4.6.
Obstetric trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Cancer care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
4.7.
Screening, survival and mortality for cervical cancer . . . . . . . . . . . . . 106
4.8.
Screening, survival and mortality for breast cancer . . . . . . . . . . . . . . 108
4.9.
Screening, survival and mortality for colorectal cancer . . . . . . . . . . . 110
Care for communicable diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
4.10. Childhood vaccination programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
4.11. Influenza vaccination for older people . . . . . . . . . . . . . . . . . . . . . . . . . 114
93
CARE FOR CHRONIC CONDITIONS
• 4.1. AVOIDABLE ADMISSIONS: RESPIRATORY DISEASES
Both asthma and chronic obstructive pulmonary
disease (COPD) are, to a considerable degree, either preventable or manageable through proper prevention or
primary care interventions. Proper management of these
chronic conditions in primary care settings can reduce
exacerbation and costly hospitalisation (Menn et al., 2012).
Hospital admission rates serve as a proxy for primary care
quality, whereby high admission rates may point to poor
care co-ordination or care continuity. They may also
indicate structural constraints such as an inadequate
supply of family physicians (Rosano et al., 2012).
Asthma is a condition that affects the airways that
carry air in and out of the lungs. Asthma symptoms are
usually intermittent and treatment can be highly effective,
even often reversing the effects of bronchial irritation. A
recent survey conducted in 70 countries showed that the
global prevalence of clinically treated asthma in adults was
estimated to be 4.5%. However, asthma prevalence in some
European countries was amongst the highest in the world,
with the Netherlands, Sweden and the United Kingdom
having prevalence rates of 15% or higher (To et al., 2012).
COPD, on the other hand, is a progressive disease. It affects
around 64 million worldwide and tobacco use is a major
risk factor (WHO, 2011a). In 2008, COPD accounted for
around 3% of total deaths in the European Union (WHO,
2011b). A Danish study found that COPD patients use over
three times as many hospital bed-days and twice as many
general practice visits as similar aged patients without
COPD; overall, COPD accounted for 6% of the total annual
health care costs of treating the population aged 40 and
over (Bilde et al., 2007).
Figure 4.1.1 shows that among the EU member states,
asthma accounts for an average of 53 hospital admissions
per 100 000 population in 2009. Asthma-related admissions
in the Slovak Republic and Latvia were more than double the
EU average, whereas Portugal, Italy, Sweden and Germany
report rates that are less than half the EU average. Adult
females experienced higher rates for asthma admissions
compared to males in all countries. On average, the female
admission rate was around 70% higher than the male
hospitalisation rate. This is in contrast to the results found
amongst children where both asthma prevalence and
94
hospital admissions are highest amongst boys (Lin and Lee,
2008). The reasons for gender differences in asthmarelated hospital admissions are not well understood
(Melero-Moreno et al., 2012). The incidence of asthma among
women has increased and “asthmatic women have poorer
quality of life and increased utilisation of health care
compared to males, despite having similar medical treatment and baseline pulmonary function” (Kynyk et al., 2011).
As shown in Figure 4.1.2, the average COPD-related
admission rate was 184 per 100 000 population in EU member
states in 2009, nearly four times greater than for asthma. By
contrast to asthma-related admissions, males had a higher
COPD admission rates than females in most countries.
Notable exceptions were Denmark, Iceland, Norway and
Sweden where there were no statistically significant differences between males and females. Ireland and Austria have
the highest admission rates for COPD. Portugal, France and
Switzerland have rates that are less than half the EU average.
Whilst some of the variation undoubtedly reflects differences
in smoking rates, there is evidence that differences in the
quality of care may also play an important role. Based on
preliminary results of a 13 European countrywide evaluation,
both process of care and outcomes vary considerably between
and within countries. The evaluation showed that approximately 50% of COPD admissions lead to a re-admission or
death within 90 days (Hartl et al., 2011).
Definitions and comparability
The asthma and COPD indicators are defined as the
number of hospital discharges of people aged 15 years
and over per 100 000 population, adjusted to take
account of the age and sex composition of each
country’s population structure. Differences in diagnosis
and coding between asthma and COPD across countries
may limit the precision of the specific disease rates.
Differences in disease classification systems, for
example between ICD-9-CM and ICD-10-AM, may also
affect the comparability of the data.
•
4.1. AVOIDABLE ADMISSIONS: RESPIRATORY DISEASES
4.1.1. Asthma hospital admission rates, population aged 15 and over, 2009 (or nearest year)
Male
Portugal
Italy
Sweden
Germany
Netherlands
Hungary
Denmark
Czech Republic
Slovenia
France
Ireland
Spain
Belgium
Austria
EU20
Poland
United Kingdom
Finland
Malta
Latvia
Slovak Republic
15
19
19
21
27
35
36
37
38
43
44
44
48
53
53
69
74
76
79
121
167
48
200
150
Rates per 100 000 population
100
50
10
0
24
14
25
13
26
15
38
17
43
26
48
24
47
26
33
43
54
32
58
28
61
23
60
35
59
46
67
39
85
51
100
46
95
54
102
52
113
130
216
116
Switzerland
Iceland
Norway
31
33
Female
20
38
23
42
23
64
27
0
60
120
180
240
Note: Rates are age-sex standardised to the 2005 OECD standard population. 95% confidence intervals represented by H.
1 2 http://dx.doi.org/10.1787/888932704798
4.1.2. COPD hospital admission rates, population aged 15 and over, 2009 (or nearest year)
Male
Portugal
France
Slovenia
Italy
Malta
Sweden
Spain
Finland
Czech Republic
Netherlands
Latvia
EU20
Germany
Slovak Republic
United Kingdom
Poland
Belgium
Hungary
Denmark
Austria
Ireland
71
79
114
126
135
137
139
146
149
154
163
184
201
206
213
217
228
248
277
310
364
243
200
100
0
Female
107
48
123
65
185
84
187
47
261
143
137
43
276
84
241
105
209
136
189
99
248
138
251
159
259
135
303
203
233
136
330
173
308
202
310
238
284
275
397
324
71
Switzerland
Iceland
Norway
91
229
400
300
45
123
207
0
100
437
200
241
226
266
300
400
500
Note: Rates are age-sex standardised to the 2005 OECD standard population. 95% confidence intervals represented by H.
1 2 http://dx.doi.org/10.1787/888932704817
95
• 4.2. AVOIDABLE ADMISSIONS: UNCONTROLLED DIABETES
The health and economic burden of diabetes continues
to rise. Across the European Union there are an estimated
31 million adults living with diabetes and many people
remain undiagnosed (Mladovsky et al., 2009). Diabetes leads
to an increased risk of cardiovascular disease, blindness,
kidney disease, lower limb amputation and mortality. Across
Europe, the treatment and management of diabetes has
been estimated to account for approximately 10% of total
health care expenditure (Zhang et al., 2010).
There is a considerable body of evidence on how best
to prevent and treat diabetes. Modest weight loss and
dietary changes can delay or even prevent the onset of
diabetes by almost 60% (DPP, 2002). Better management of
blood glucose levels in Type 2 diabetes patients can reduce
microvascular complications by 25% (UKPDS, 1998) and
non-fatal myocardial infarctions by 17% (Ray et al., 2009).
However, health care systems have historically struggled
with optimising diabetes care and many patients do not
seek treatment until complications have set in.
Figure 4.2.1 shows the extent to which the failure of
effectively controlling and managing diabetes manifests in
avoidable hospital admissions. The figure shows that the
EU average for uncontrolled diabetes admissions (without
complications) is 50 per 100 000 population. For admissions
with short- and long-term diabetes complications, the
EU average is 109 per 100 000 population. Males tend to have
higher admission rates than females even though evidence
suggests that there are no significant gender differences in
diabetes prevalence (DECODE Study Group, 2003).
Figure 4.2.2 examines the relationship between diabetes prevalence and avoidable admissions. The line in the
graph indicates that countries with higher disease prevalence tend to have higher rates of diabetes-related admissions. However, substantial variations remain even after
controlling for disease prevalence, with countries such as
Austria, the Czech Republic and Poland having higher rates
of admissions, whereas Spain, Switzerland and Portugal
experience lower rates. The variation in diabetes-related
hospital admissions (after taking prevalence into account)
suggests that other factors, such as adherence to highquality diabetes care, may also play a role.
In combating the challenges posed by diabetes, a
number of countries have introduced initiatives to reduce
the impact of the disease. For example, a number of
European countries have recently introduced taxes on
unhealthy food and drink to promote better nutrition and
reduce obesity, an important risk factor for diabetes (OECD,
2012b). Austria has introduced a disease management
programme, with early indications showing some success in
process quality and enhanced weight loss, but no significant
improvement in diabetes control (Sönnichsen et al., 2010).
As part of the United Kingdom’s Quality and Outcomes
Framework, up to 25% of British practice income is linked to
performance, including a range of diabetes indicators such
as glucose control, medication compliance and foot care
96
(Adler, 2012). In France, results from a two year pay-forperformance pilot has shown positive results in diabetes
management through better medication compliance and
glucose control (Polton, 2012).
Alongside national initiatives, there are also some
recent examples of international diabetes collaborations.
In April 2012, the European Diabetes Leadership Forum
brought together a wide range of stakeholders to produce
the Copenhagen Roadmap outlining initiatives to improve
diabetes prevention, early detection and intervention as
well as management and control (see www.diabetesleadershipforum.eu for more information). In the European Union,
the EUBIROD Project has developed a European Diabetes
Register that brings together data from across Europe. The
registry allows comparisons across Europe on how diabetes
is treated and share knowledge to reduce the burden of
diabetes (EC, 2012b).
The indicator for uncontrolled diabetes hospital
admission rates with and without complications is
based on the sum of the three indicators: i) shortterm diabetes complications; ii) long-term diabetes
complications; and iii) uncontrolled diabetes without
complications.
The indicator for admissions with short-term diabetes complications is defined as all non-maternal/
non-neonatal hospital admissions of people aged
15 years and over with a principal diagnosis code for
diabetes short-term complications including coma
and ketoacidosis, caused by a shortage of insulin in
the body. The indicator for long-term diabetes
complications is defined similarly but where the
principal diagnosis code indicates the presence of
long-term diabetes complications such as renal, eye
or circulatory complications. The indicator for
uncontrolled diabetes without complications is
defined as all non-maternal/non-neonatal hospital
admissions of people aged 15 years and over with a
principal diagnosis code for uncontrolled diabetes,
without mention of a short-term or long-term
complication.
The rates are per 100 000 population and have been
adjusted to take account of the age and sex composition
of each country’s population structure. Differences in
coding practices among countries may affect the
comparability of data. Differences in disease classification systems, for example between ICD-9-CM and
ICD-10-AM, may also affect the comparability of the
data.
•
4.2. AVOIDABLE ADMISSIONS: UNCONTROLLED DIABETES
4.2.1. Uncontrolled diabetes hospital admission rates with and without complications,
population aged 15 and over, 2009 (or nearest year)
With complications
Without complications
Male
3
64
169
170
253
218
262
211
Czech Republic
31
293
298
Austria
188
34
46
411
45
20
Iceland
19
Switzerland
71
50
81
86
Norway
47
53
200
149
Poland
66
220
186
Germany
50
159
191
135
Malta
41
119
400
300
192
126
EU15
50
109
167
180
114
Finland
78
175
119
Ireland
32
78
162
140
153
Denmark
65
115
141
103
Latvia
18
130
82
108
97
Sweden
66
63
108
86
Slovenia
42
77
85
76
Portugal
16
81
81
64
Italy
33
58
Spain
United Kingdom
24
50
Female
54
100
110
0
0
100
200
300
400
500
Note: Rates are age-sex standardised to the 2005 OECD standard population. Male and female rates refer to the sum of admissions with and without
diabetes complications.
1 2 http://dx.doi.org/10.1787/888932704836
4.2.2. Uncontrolled diabetes hospital admission rates and prevalence of diabetes, 2009 (or nearest year)
Admissions per 100 000 population
400
R 2 = 0.18
AUT
350
300
250
CZE
POL
DEU
200
DNK
150
IRL
MLT
FIN
LVA
NOR
SVN
SWE
100
GBR
ESP
ISL
50
PRT
ITA
CHE
0
0
1
2
3
4
5
6
7
8
9
10
Prevalence of diabetes (%)
Note: Prevalence estimates of diabetes refer to adults aged 20-79 years and data are age-standardised to the World Standard Population. Hospital
admission rates refer to the population aged 15 and over and are age-sex standardised to the 2005 OECD standard population.
Source: IDF (2009) for prevalence estimates; OECD Health Data 2012 for hospital admission rates.
1 2 http://dx.doi.org/10.1787/888932704855
97
ACUTE CARE •
4.3. IN-HOSPITAL MORTALITY FOLLOWING ACUTE MYOCARDIAL INFARCTION
Care for AMI (heart attack) has changed dramatically
in recent decades (Khush et al., 2005; Gil et al., 1999). Clinical practice guidelines, such as those developed by the
European Society of Cardiology, provide clinicians with the
best available evidence on how to optimise care. Numerous
studies have shown that greater compliance with guidelines improves health outcomes (e.g. Schiele et al., 2005;
Eagle et al., 2005). However, a considerable proportion of
AMI patients do not receive recommended care (Brekke
and Gjelsvik, 2009; Kotseva et al., 2009).
AMI case-fatality rates refer to the percentage of
patients who die within 30 days after a hospital admission
for AMI. This rate is a good measure of acute care quality
because there is a clear link between the processes of care
and health outcomes (Bradley et al., 2006). AMI case-fatality
rates have been used for hospital benchmarking in several
countries including Denmark and the United Kingdom, and
have been used in the academic literature as a wider
marker for hospital quality (e.g. Kessler and Geppert, 2005;
Cooper et al., 2011). However, the indicator is influenced by
not only the quality of care provided in hospitals but also
differences in hospital transfers, average length of stay,
emergency retrieval times and average severity of AMI.
countries. Figure 4.3.2 presents AMI case-fatality rates for
the nine countries for which both admission-based and
patient-based data are available. It confirms that patientbased indicators are higher than hospital-based rates,
but the degree of cross-country variation is considerably
less compared to the admission-based indicator. The
average patient-based AMI case-fatality rate is 6.9% and
ranges from 5.5% (Sweden) to 7.8% (Slovenia).
Case-fatality rates for AMI have decreased over time,
with almost all countries recording sizeable reductions
between 2000 and 2009 (Figure 4.3.3). The AMI case-fatality
rate for the ten EU member states reporting data over this
period fell by nearly 50% between 2000 and 2009. These
substantial improvements reflect better and more reliable
processes of care, in particular with respect to rapid
re-opening of the occluded arteries. Most of these improvements were made between 2000 and 2005, with fewer gains
in more recent years.
Figure 4.3.1 shows the crude and age-standardised
AMI case-fatality rates, when the death occurs within a
30-day period and in the same hospital as the initial AMI
admission. The average age-standardised AMI case-fatality
rate across the European Union is 5% but rates vary widely
between countries. The lowest age-standardised rates are
found in Denmark and Norway (2.3% and 2.5%, respectively) and the highest rate is in Belgium (8.6%), although
some of the variation between countries may be explained
by differences in data definitions (see box on “Definitions
and comparability”). The Minister of Health in Belgium
introduced new reforms in 2012 that aim to minimise
res ponse time for ca rdia c interventions, imp rove
co-operation within provider networks, set new care
standards, as well as new minimum activity thresholds in
hospitals which are aimed at reducing AMI case-fatality
rates (Onkelinx, 2012).
In-hospital case-fatality rate following AMI is
defined as the number of people who die within
30 days of being admitted (including same day admissions) to hospital with an AMI. Ideally, rates would
be based on individual patients; however, not all
countries have the ability to track patients in and out
of hospitals, across hospitals or even within the same
hospital because they do not currently use a unique
patient identifier. In order to increase country
coverage, this indicator is also presented based on
individual hospital admissions and restricted to
mortality within the same hospital, so differences in
practices in discharging and transferring patients
may influence the findings. In counting the number
of AMI admissions, Belgium excludes transfers to
other hospitals from the denominator leading to
some over-estimation.
Patient-based data, which follow patients in and out of
hospitals and across hospitals, is a more robust indicator
for international comparison than admission-based data,
as admission-based data may bias case-fatality rates
downwards if unstable cardiac patients are commonly
transferred to tertiary care centres. Unfortunately, patientbased data is only available for a relatively small group of
Both crude and age-sex standardised rates are
presented for admission-based data. Standardised
rates adjust for differences in age (45+ years) and sex
and facilitate more meaningful international comparisons. Crude rates are likely to be more meaningful for
internal consideration by individual countries.
98
ACUTE CARE
•
4.3. IN-HOSPITAL MORTALITY FOLLOWING ACUTE MYOCARDIAL INFARCTION
4.3.1. Admission-based in-hospital case-fatality rates within 30 days after admission for AMI,
Crude rates
Age-sex standardised rates
4.5
2.5
3.0
5.0
7.1
6.9
8.6
10.4
6.8
9.7
7.3
5.7
6.6
8.6
5.7
5.6
7.2
5.3
8.4
9.1
5.0
5.2
7.7
5.0
4.8
6.4
4.7
6.6
4.3
4.8
3.9
4.3
6.5
3.7
4
2.9
3.9
2.3
6.6
8
6.8
12
5.2
10.6
13.4
Rates per 100 patients
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Note: Rates are age-sex standardised to the 2005 OECD standard population (45+). 95% confidence intervals represented by H.
1 2 http://dx.doi.org/10.1787/888932704874
4.3.2. Comparing admission-based and patient-based in-hospital case-fatality rates within 30 days
after admission for AMI, selected EU countries, 2009 (or nearest year)
Admission-based rates (same hospital)
Patient-based rates (in and out of hospital)
2.9
2.3
4.8
7.2
5.2
5.3
6.8
6.8
6.7
4.3
7.6
3
3.9
6
4.7
5.5
6.4
6.9
9
5.2
7.8
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1 2 http://dx.doi.org/10.1787/888932704893
4.3.3. Reduction in in-hospital case-fatality rates within 30 days after admission for AMI,
9.0
8.1
11.1
4.2
5.7
6.6
6.8
6.6
5.6
5.3
6.3
3.8
5.5
4.8
4.7
9.4
9.0
5.2
8.3
8.9
10.5
4.3
5.7
6.6
6.2
2.5
2.3
4
2.9
3.4
3.9
6
4.3
6.2
6.3
10
8
2009
7.6
9.9
2005
10.3
2000
12
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1 2 http://dx.doi.org/10.1787/888932704912
99
ACUTE CARE •
4.4. IN-HOSPITAL MORTALITY FOLLOWING STROKE
In Europe, stroke and other cerebrovascular diseases
account for around 9% of all deaths and are the third most
common cause of death (OECD, 2012a, based on the WHO
Mortality Database). Stroke is also a major cause of adult
disability. Around one third of all stroke incidents lead to
permanent sequelae and dependency (WHO, 2004b). In
ischemic stroke, representing about 85% of cases, the blood
supply to a part of the brain is interrupted, leading to a
necrosis of the affected part, while in hemorrhagic stroke,
the rupture of a blood vessel causes bleeding into the brain,
usually causing more widespread damage.
Treatment for ischemic stroke has advanced dramatically over the last decades. Since the 1990s, clinical trials
have demonstrated clear benefits of thrombolytic treatment for ischemic stroke in both European (e.g. Hacke et al.,
1995) and non-European countries (e.g. Mori et al., 1992;
NINDS, 1995). Dedicated stroke units were introduced in
many countries, to facilitate timely and aggressive diagnosis and therapy for ischemic and haemorrhagic stroke
victims, achieving better survival than usual care (Seenan
et al., 2007). Whilst there is only limited international data
on stroke unit access, there are some indications that
access varies across and within countries (OECD, 2003;
Abilleira et al., 2012; Rudd et al., 2007).
Stroke survival reflects quality of acute care, particularly effective treatment methods such as thrombolysis
and prompt and adequate care delivery (Abilleira et al.,
2012). Consequently, stroke case-fatality rates have been
used for hospital benchmarking within and between OECD
countries.
While the standardised case-fatality rate for ischemic
stroke was about 5.4% on average across EU member states
in 2009, there were large differences between the highest
rate in Slovenia (9.7%) and the lowest rate in Denmark
(2.6%) (Figure 4.4.1). The average standardised rate for
hemorrhagic stroke is 20.2% (Figure 4.4.2), about four times
greater than the rate for ischemic stroke, reflecting the
more severe effects of intracranial bleeding. There is a
six-fold cross-country difference between the highest and
lowest percentage of in-hospital case-fatality for hemorrhagic stroke. In Finland, 6.5% of hemorrhagic stroke
admissions lead to a death within 30 days, whereas in
Belgium the corresponding figure is 38.6%. One potential
reason for this is that patients are not systematically transported to hospitals with dedicated stroke units in Belgium
so that some patients miss out on optimal care. The
variation between countries may also, in part, be explained
by differences in data definitions (see box on “Definitions
and comparability”).
There is a high degree of correlation between the two
case-fatality indicators for ischemic and hemorrhagic
stroke, with countries that achieve better survival for one
type of stroke tending to do well for the other type. This
100
suggests that system-based factors such as access to specialised stroke care, average length of stay, emergency
retrieval times as well as stroke severity may also influence
the case-fatality rates.
Between 2000 and 2009, case-fatality rates for ischemic stroke declined by over 20% across EU member states
(Figure 4.4.3). These reductions suggest overall improvements in the quality of care for stroke patients, with gains
made in most countries for which data is available. However, improvements were not uniform across countries.
Improvements in Ireland and Portugal were below the
EU average, while the rate in Luxembourg did not change
significantly over the period. On the other hand, Norway
was able to reduce its fatality rate by 55% between 2000
and 2009. The improvements in case-fatality rates can at
least be partially attributed to the high level of access to
dedicated stroke units in countries such as Norway,
Denmark and Sweden (Indredavik, 2009).
In-hospital case-fatality rate following ischemic
and hemorrhagic stroke is defined as the number of
people who die within 30 days of being admitted
(including same day admissions) to hospital. Ideally,
rates would be based on individual patients; however,
not all countries have the ability to track patients in
and out of hospitals, across hospitals or even within
the same hospital because they do not currently use a
unique patient identifier. Therefore, this indicator is
based on unique hospital admissions and restricted
to mortality within the same hospital, so differences
in practices in discharging and transferring patients
may influence the findings. In counting the number
of stroke admissions, Belgium excludes transfers to
other hospitals from the denominator leading to
some over-estimation.
The Czech Republic, Denmark, Finland, Luxembourg,
the Netherlands, Poland, Slovenia, Sweden and the
United Kingdom also provided patient-based (in and out
of hospitals) data. Their relative performance is generally similar as the case-fatality rate within the same
hospital, although the rates are obviously higher.
Both crude and age and sex standardised rates are
presented. Standardised rates adjust for differences
in age (45+ years) and sex and facilitate more meaningful international comparisons. Crude rates are
likely to be more meaningful for internal consideration by individual countries.
ACUTE CARE
4.4.1. In-hospital case-fatality rates within 30 days after
admission for ischemic stroke, 2009 (or nearest year)
Crude rates
Denmark
6.3
7.3
3.4
Sweden
Germany
Luxembourg
9.6
19.3
7.1
8.6
Slovenia
9.7
30.6
24.3
28.8
25.1
15.3
Slovak Republic
29.0
25.5
15.3
Belgium
38.6
Norway
19.7
14.1
Switzerland
5
10
15
20
45.8
16.6
11.6
Iceland
8.2
4.3
27.4
25.2
23.9
Slovenia
8.0
2.8
23.9
Luxembourg
6.5
2.8
27.3
25.4
23.0
Spain
12.9
24.1
22.4
Ireland
10.7
Belgium
20.2
Portugal
6.8
Slovak Republic
23.3
Netherlands
11.1
6.2
22.2
17.6
Czech Republic
10.2
6.1
United Kingdom
19.7
16.4
United Kingdom
11.0
6.1
Portugal
17.6
13.8
21.3
18.0
10.3
Ireland
17.2
EU16
5.8
Spain
0
12.8
8.6
5.7
Czech Republic
Switzerland
Sweden
Italy
5.4
Netherlands
Iceland
15.6
12.1
Denmark
8.3
4.5
EU16
Austria
8.0
4.0
6.5
9.3
Germany
8.4
3.9
Norway
Crude rates
Finland
3.1
Italy
5.8
2.8
Austria
4.4. IN-HOSPITAL MORTALITY FOLLOWING STROKE
4.4.2. In-hospital case-fatality rates within 30 days after
admission for hemorrhagic stroke, 2009 (or nearest year)
4.6
2.6
Finland
•
14.8
0
10
19.9
20
30
40
50
Note: Rates are age-sex standardised to the 2005 OECD standard
population (45+). 95% confidence intervals represented by H.
Note: Rates are age-sex standardised to the 2005 OECD standard
population (45+). 95% confidence intervals represented by H.
1 2 http://dx.doi.org/10.1787/888932704931
1 2 http://dx.doi.org/10.1787/888932704950
4.4.3. Reduction in in-hospital case-fatality rates within 30 days after admission for ischemic stroke,
2005
2000
2009
8.1
6.1
6.2
6.1
7.1
7.0
6.9
6.1
5.8
5.7
3.5
4.7
5.5
6.0
3.0
3.9
4.2
3.8
5.2
4.1
2.8
2.8
3.1
3.9
3.7
3.9
3.2
2.6
3.4
4
3.5
6
6.6
4.5
8
7.2
10
7.9
9.0
9.7
12
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1 2 http://dx.doi.org/10.1787/888932704969
101
PATIENT SAFETY • 4.5. PROCEDURAL OR POSTOPERATIVE COMPLICATIONS
Several European studies have documented that
between 8% and 12% of patients admitted to hospitals
suffer from adverse effects whilst receiving health care
(UK Department of Health, 2000; WHO Europe, 2012b). The
European Commission estimates that without any policy
changes, there are likely to be 10 million adverse events
related to hospitalisations (including infection-related
ones) in the European Union per year, of which almost
4.4 million would be preventable (EC, 2008d).
Patient safety has, in recent years, become an important part of the policy agenda in Europe. In 2009, the
Council of the European Union adopted a recommendation
on patient safety, including the prevention and control of
health care associated infections (European Union, 2009).
This recommendation is intended to bring about a political
commitment from all EU member states to address the
patient safety challenge.
Figures 4.5.1 to 4.5.4 show reported complication rates
related to surgical and medical care for four patient safety
indicators: i) sentinel events, such as a foreign body left in a
person during a surgical procedure, are those that in theory
and practice should never happen and thus whose occurrence indicates failure of safeguards to protect patients
during care delivery; ii) accidental puncture or laceration
during a surgical procedure is a recognised risk, but increased
rates of such complications may indicate system problems;
iii) postoperative pulmonary embolism and deep vein
thrombosis cause unnecessary pain and death, but can be
prevented through the appropriate use of anticoagulants and
other preventive measures; and iv) sepsis after elective
surgery is a severe complication that can lead to multiple
organ dysfunction and death. Many cases of postoperative
sepsis can be prevented through infection prevention
measures such as hand hygiene, sterile surgical techniques,
good postoperative care and, where necessary, the appropriate use of prophylactic antibiotics.
Comparable data are available for between eight and
thirteen European countries, depending on the indicator.
There are considerable differences across countries for
these four patient safety indicators. Whereas Denmark and
Germany report complication rates that are below the
EU average for each of the four patient safety indicators,
other countries show less consistent results. For example,
Belgium, France, Ireland and Switzerland perform well on
some indicators but report worse than EU average results
for others.
Differences in the prevalence of patient safety complications across countries may reflect – at least in part –
102
differences in the willingness of health workers to admit to
medical errors as well as differences in the sensitivity of
monitoring or surveillance systems across countries.
Nevertheless, these indicators do show that numerous
patients have been affected by patient safety events. International efforts to harmonise documentation and data
systems, and the results of ongoing validation studies, will
provide more information on the validity and reliability of
patient safety measures based on administrative hospital
data in the future.
Patient safety indicators are derived from the Quality
Indicators developed by the US Agency for Healthcare
Research and Quality (AHRQ). AHRQ’s patient safety
indicators are a set of indicators that provide information on hospital complications and adverse events
following surgeries, procedures, and childbirth. The
indicators were developed after a comprehensive literature review, analysis of ICD-9-CM codes, clinician
panel review, implementation of risk adjustment, and
empirical analyses (AHRQ, 2006).
All procedural or postoperative complications are
defined as the number of discharges with ICD codes
for complication in any secondary diagnosis field,
divided by the total number of discharges (medical
and surgical or surgical only) for patients aged 15 and
older. Data are based on administrative hospital
discharge data. The rates have been age/sex standardised, apart from postoperative sepsis rate (this is
due to the use of modified exclusion criteria within
the algorithm for the calculation of this indicator).The
patient safety rates have also been adjusted by the
average number of secondary diagnoses (SDx)
(Drösler et al., 2011) in order to improve cross-country
comparability. Despite this adjustment, the results for
the two countries (Finland and Italy) that are reporting less than 1.5 diagnoses per record may be underestimated. Differences in coding practice, coding
rules (e.g. definition of principal and secondary
diagnoses), coding for billing purposes and the use of
diagnosis type markers (e.g. “present at admission”)
may also influence indicators.
PATIENT SAFETY
4.5.1. Foreign body left in during procedure,
SDx-adj. standardised rate
Italy
2.6
2.0
Italy1
4.5
3.4
Denmark
3.4
France
1.5
1
4.1
4.2
EU11
114
100
117
65
119
98
155
155
163
EU11
4.8
5.5
France
5.4
170
144
174
170
205
United Kingdom
6.1
Spain
Sweden
5.6
5.1
5.7
United Kingdom
29
Finland1
Portugal
255
Portugal
9.7
Belgium
13.3
Switzerland
4
8
546
Belgium
7.8
0
122
75
13
1
Ireland
3.3
Germany
73
Spain
2.7
Age-sex standardised rate
160
Germany
2.4
Sweden
Finland
2.0
Ireland
4.5. PROCEDURAL OR POSTOPERATIVE COMPLICATIONS
4.5.2. Accidental puncture or laceration,
1.3
1.8
Denmark
•
13.8
432
356
392
Switzerland
0
12
16
Per 100 000 hospital discharges
200
400
600
Per 100 000 hospital discharges
Note: Some of the variations across countries are due to different
classification systems and recording practices. 95% confidence intervals
represented by H.
SDx: Secondary diagnoses adjustment.
1. The average number of secondary diagnoses is < 1.5.
represented by H.
1 2 http://dx.doi.org/10.1787/888932704988
1 2 http://dx.doi.org/10.1787/888932705007
4.5.3. Postoperative pulmonary embolism
or deep vein thrombosis, 2009 (or nearest year)
4.5.4. Postoperative sepsis,
538
Belgium
708
Germany
203
541
335
Spain
285
705
754
Denmark
595
Germany
378
422
Denmark
674
France
506
Crude rate
858
215
Italy1
536
528
EU11
694
Sweden
926
582
389
Portugal
1 017
1 050
EU7
664
299
Finland1
680
1 062
1 099
Spain
697
Ireland
692
722
749
Sweden
France
391
Switzerland
0
200
1 224
1 863
1 951
Ireland
902
548
428
Norway
1 411
Belgium
820
812
780
United Kingdom
152
Switzerland
354
634
400
600
800
1 000
Rates per 100 000 hospital discharges
represented by H.
0
500
1 000
1 500
2 000
Rates per 100 000 hospital discharges
classification systems and recording practices.
1 2 http://dx.doi.org/10.1787/888932705045
1 2 http://dx.doi.org/10.1787/888932705026
103
PATIENT SAFETY • 4.6. OBSTETRIC TRAUMA
The patient safety indicators related to obstetric trauma
flag cases of potentially preventable third- and fourth-degree
perineal tears during vaginal delivery. Such tears extending to
the perineal muscles, anal sphincter and bowel wall require
surgical treatment after birth. Possible complications include
continued perineal pain and anal incontinence. A recent
study found that around 10% of women who had such tears
will suffer from faecal incontinence initially (compared to
3% of women who do not have a tear). Almost 45% of women
with initial symptoms had remaining problems after four to
eight years (Sundquist, 2012).
The proportion of deliveries involving higher degree
lacerations is a useful indicator of the quality of obstetrical
care. These types of tears are not possible to prevent in all
cases, but can be reduced by employing appropriate labour
management and care standards. A third- or fourth-degree
trauma is more likely to occur in the case of first vaginal
delivery, baby’s high birth weight, labour induction, occiput
posterior position, prolonged second stage of labour and
instrumental delivery. Obstetric trauma indicators have
been used by the US Joint Commission as well as by different international quality initiatives analysing obstetric
data (AHRQ, 2007). As the risk of a perineal laceration is
significantly increased in instrument-assisted labour
(vacuum, forceps), rates for this patient population are
reported separately.
Figures 4.6.1 and 4.6.2 show the variation in reported
rates of obstetric trauma during vaginal delivery with and
without instrument. The rate of obstetric trauma after
vaginal delivery with instrument shows high variability
among countries. Reported rates vary from below 3%
(Slovenia, Portugal, France, Belgium, and Italy) to more
than 10% (Sweden). Rates of obstetric trauma after vaginal
delivery without instrument range from 0.2% to 3.2%.
Denmark, Sweden and Switzerland stand out as having
the highest reported rates for obstetric trauma without
instrument. The lower rate of obstetric trauma in Finland
compared to other Nordic countries (Denmark, Norway,
and Sweden) may be explained by the variation in delivery
method and episiotomy practice (Laine et al., 2009).
104
Furthermore, findings from a recent study showed that
enhanced midwifery skills in managing vaginal delivery
reduce the risk of obstetric anal sphincter injuries (Hals
et al., 2010).
There is a strong relationship between the two obstetric trauma indicators shown in Figures 4.6.1 and 4.6.2.
Countries such as Belgium, Finland, France, Italy, Portugal,
Slovenia and Spain report lower than EU average obstetric
trauma rates for both indicators. Latvia, on the other hand,
has high rates of trauma when an instrument was used but
low rates when an instrument was not used during delivery. This makes it more difficult to draw any clear conclusions from these two indicators for Latvia.
The two obstetric trauma indicators are defined as
the proportion of instrument assisted/non-assisted
vaginal deliveries with third- and fourth-degree
obstetric trauma codes in any diagnosis and procedure field. Therefore, any differences in the definition
of principal and secondary diagnoses have no influence on the calculated rates.
Several differences in data reporting across countries
may influence the calculated rates of obstetric patient
safety indicators. These relate primarily to differences
in coding practice and data sources. Some countries
report the obstetric trauma rates based on administrative hospital data and others based on obstetric register. There is some evidence that registries produce
higher quality data and report a greater number of
obstetric trauma events compared to administrative
datasets (Baghestan et al., 2007).
See box on “Definitions and comparability” for
Indicator 4.5 “Procedural or postoperative complications”, for more information on patient safety
indicators.
PATIENT SAFETY
•
4.6. OBSTETRIC TRAUMA
4.6.1. Obstetric trauma, vaginal delivery with instrument, 2009 (or nearest year)
Crude rates per 100 patients
12
11.1
9.8
10
8
7.7
7.5
6.6
6.3
6
4.7
4
2
3.8
2.1
1.7
1.6
3.4
3.3
3.1
2.8
2.6
3.6
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1 2 http://dx.doi.org/10.1787/888932705064
4.6.2. Obstetric trauma, vaginal delivery without instrument, 2009 (or nearest year)
Crude rates per 100 patients
3.5
3.2
3.1
3.1
3.0
2.5
2.2
2.1
2.1
2.0
2.0
1.5
1.3
1.3
1.0
0.5
0.4
0.7
0.6
0.6
0.5
0.4
0.7
0.2
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1 2 http://dx.doi.org/10.1787/888932705083
105
CANCER CARE
• 4.7. SCREENING, SURVIVAL AND MORTALITY FOR CERVICAL CANCER
Cervical cancer is mainly the outcome of persistent
infection with human papillomavirus (HPV), which
accounts for approximately 95% of all cases (IARC, 1995;
Franco et al., 1999). Every year 61 000 new cervical cancers
are diagnosed in Europe (IARC, 2011).
Precancerous changes can be detected and treated
before progression to cancer occurs, making cervical
cancer highly preventable. Population-based cervical
screening programmes have been promoted by the Council
of the European Union and the European Commission
(European Union, 2003; EC, 2008c), but the periodicity and
target groups vary among member states.
Figure 4.7.1 shows cervical screening rates across
European countries in the years 2000 and 2010 for women
aged 20-69 years. In 2010, Latvia, Germany, the United
Kingdom, and Norway reported coverage close to 80% of the
target population. Whilst overall screening rates across the
European Union improved slightly over the past decade,
several countries, including Finland, Hungary, Iceland,
Norway, the Slovak Republic and the United Kingdom
witnessed a decline in screening rates between 2000
and 2010.
Survival rates reflect both how early the cancer was
detected and the effectiveness of the treatment. It is a key
measure of the effectiveness of health care systems to treat
potentially fatal diseases and track progress over time.
Figure 4.7.2 shows a small gain in five-year cervical cancer
survival rates in the European Union between 1997-2002
and 2004-09, although gains were not uniform across
countries. Of the 11 EU member states reporting data in
both periods, seven recorded modest gains in survival rates
whereas four countries (Denmark, Finland, France and
Germany) reported a small decline, although the reduction
was not statistically significant. Norway reported the
highest rates as well as the highest gain in cervical cancer
survival, with 78.2% of patients surviving five years after
diagnosis.
Mortality rates reflect the effect of cancer care in past
years, the impact of screening, improved diagnosis of
early-stage cancers as well as incidence. Mortality rates for
cervical cancer declined in most European countries
between 2000 and 2010, apart from Bulgaria, the Former
Yugoslav Republic of Macedonia and Croatia, Greece and
Ireland (Figure 4.7.3). For some countries such as Lithuania
and Romania, mortality rates remain well above the
EU average.
Since the development of a vaccine against some HPV
types, vaccination programmes have been implemented in
most EU countries. By May 2012, 17 out of 27 EU member
106
states had implemented rout ine H PV va ccina tion
programmes. In most cases the vaccination programmes
are financed by the national health systems. However, in
Austria the vaccination is entirely covered by the recipient,
and in Belgium and France recipients contribute 25% and
35% of the payment, respectively (ECDC, 2012b). Since its
introduction, there has been an active policy and research
debate about the impact of the vaccine on cervical cancer
screening strategies (Goldhaber-Fiebert et al., 2008; Wheeler
et al., 2009).
Screening rates for cervical cancer reflect the
proportion of women who are eligible for a screening
test and actually receive the test. As policies regarding
screening periodicity and target population differ
across countries, the rates are based on each country’s
specific policy. Some countries ascertain screening
based on surveys and others based on encounter data,
which may influence the results. Survey-based results
may be affected by recall bias. If a country has an
organised programme, but women receive a screening
outside the programme, rates may also be underreported. Survey data are reported only when
programme data are not available.
Relative cancer survival rates reflect the proportion
of patients with a certain type of cancer who are still
alive after a specified time period (commonly five
years) compared to those still alive in absence of the
disease. Relative survival rates capture the excess
mortality that can be attributed to the diagnosis. For
example, a relative survival rate of 80% does not
mean that 80% of the cancer patients are still alive
after five years, but that 80% of the patients that were
expected to be alive after five years, given their age
at diagnosis and sex, are in fact still alive. All
the survival rates presented here have been agestandardised using the International Cancer Survival
Standard (ICSS) population. The survival rates are not
adjusted for tumour stage at diagnosis, hampering
assessment of the relative impact of early detection
and better treatment.
See Indicator 1.5 “Mortality from cancer” for definition, source and methodology underlying the cancer
mortality rates.
CANCER CARE
•
4.7. SCREENING, SURVIVAL AND MORTALITY FOR CERVICAL CANCER
4.7.1. Cervical screening, percentage women screened
aged 20-69, 2000 to 2010 (or nearest year)
2000
Austria
2010
1997-2002
2
78.7
82.0
78.5
78.2
78.4
76.5
74.9
1
Sweden1
Switzerland 2
Slovenia1
Sweden
65.6
68.1
Netherlands
63.1
67.0
Finland
67.9
66.3
72.1
Belgium
Finland1
71.1
70.3
69.8
Portugal
Greece 2
69.7
Denmark
France 2
2
Spain 2
EU24
63.3
62.9
62.0
62.5
Czech Republic
51.8
Luxembourg1
61.7
62.2
Austria
58.0
33.3
1
58.0
58.8
United Kingdom
47.4
Bulgaria 2
44.0
Italy1
54.3
57.6
Ireland
46.8
Estonia1
Latvia
48.7
40.0
28.4
23.7
23.2
22.9
1
Slovak Republic1
78.9
78.5
74.0
65.0
1. Programme.
25
50
68.8
Norway
78.2
Iceland
9.7
0
44.7
Malta
Norway1
Turkey
65.5
63.0
62.1
Malta 2
1
63.1
63.9
Germany
58.6
63.2
Belgium1
Iceland
65.4
64.3
France
66.3
65.6
66.1
Netherlands1
1
65.1
EU11
68.5
67.3
Denmark1
Hungary
65.3
69.1
Cyprus 2
Czech Republic
67.5
70.2
80.5
Germany2
Poland
2004-09
Slovenia
81.5
Latvia 2
United Kingdom
4.7.2. Cervical cancer five-year relative survival rate,
1997-2002 and 2004-09 (or nearest period)
75
100
Women screened (%)
67.3
0
2. Survey.
30
60
90
Survival (%)
Note: 95% confidence intervals represented by H.
1 2 http://dx.doi.org/10.1787/888932705102
1 2 http://dx.doi.org/10.1787/888932705121
4.7.3. Cervical cancer mortality, females, 2000 to 2010 (or nearest year)
2010
2000
13.4
14.8
16
11.6
14
5.8
7.1
6.9
7.5
7.5
6.3
6.9
6.1
5.7
4.1
3.2
3.3
1.4
2.3
2.8
3.6
4.0
3.6
3.9
3.6
3.0
3.0
3.3
2.5
2.4
2.5
2.5
3.3
2.3
4.9
5.8
1.5
1.5
2.7
2.2
2.6
2.0
1.9
1.8
1.5
1.7
2.1
1.4
0.7
0.9
0.8
1.0
2.2
4
2.4
2.1
4.1
4.8
5.1
6
2
5.9
8
7.4
7.3
10
9.0
9.3
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1 2 http://dx.doi.org/10.1787/888932705140
107
CANCER CARE
• 4.8. SCREENING, SURVIVAL AND MORTALITY FOR BREAST CANCER
Breast cancer is the most prevalent form of cancer
among women, with 425 000 new cases diagnosed each
year in Europe (IARC, 2011). Risk factors that increase a
person’s chance of getting this disease include, but are not
limited to, age, family history of breast cancer, oestrogen
replacement therapy and alcohol. Annual incidence in
Europe is expected to rise to 466 000 cases by 2020. Variation in breast cancer care across European countries is
indicated by mammography screening rates in women
aged 50-69 years, relative survival rates, and mortality
rates.
EU guidelines (EC, 2006) promote a desirable target
screening rate of at least 75% of eligible women in European
member states but in 2010 only three countries had reached
this target. There is considerable uniformity amongst
national breast screening programmes, in terms of the target
age group and recommended time interval between screens.
Participation, however, continues to vary considerably across
European countries, ranging from 8% in Romania, 15% in
Turkey and 16% in the Slovak Republic, to over 80% in Finland,
Slovenia and the Netherlands (Figure 4.8.1). This variation
may, in part, be explained by programme longevity, with
some countries having well established programmes and
others commencing programmes more recently (von Karsa
et al., 2008). However, screening rates fell in a number of
countries in the past decade including Norway and the United
Kingdom. Rates in Hungary and the Slovak Republic have
increased substantially, although they remain well below the
EU average.
Breast cancer survival rates reflect advances in public
health interventions, such as greater awareness of the
disease, screening programmes, and improved treatment. In
particular, the introduction of combined breast conserving
surgery with local radiation and advances in adjuvant and
neoadjuvant therapy has increased survival as well as the
quality of life of survivors (Mauri et al., 2008). Figure 4.8.2
shows that the average EU relative five-year breast
cancer survival rate around the period 2004-09 was 82%.
Between 1997-2002 and 2004-09, survival rates have
improved in all countries. Survival rates around 2004-09
were highest in France, Finland, Belgium, Sweden, Norway
and Iceland (with rates reaching 86% to 87%). Whilst survival
108
rates remain below 80% in Latvia, the Czech Republic and
Slovenia, the data shows that for the latter two countries
survival rates improved considerably over that period.
Breast cancer mortality rates have declined in all EU
member states over the past decade (Figure 4.8.3). The
reduction in mortality rates is a reflection of improvements
in early detection and treatment of breast cancer. Countries
that reported relatively high mortality rates in 2000 recorded
the biggest declines in breast cancer mortality. These
countries include the Czech Republic, Estonia, Luxembourg,
the Netherlands, Norway and the United Kingdom.
Denmark also recorded substantial falls over the last decade
but its mortality rate was the highest in 2010. The level of
variation across the European Union has declined substantially over the period. In 2000, eight EU member states
reported mortality rates higher than 30 deaths per
100 000 females, but in 2010 mortality rates were below this
rate in all countries. Despite these gains over the past
decade, around 129 000 deaths are caused by breast cancer
each year in European countries.
Mammography screening rates reflect the proportion of eligible women who are actually screened. As
policies regarding target age groups and screening
periodicity differ across countries, the rates are based
on each country’s specific policy. Some countries
ascertain screening based on surveys and others
based on encounter data, and this may influence
results. Survey-based results may be affected by recall
bias. If a country has an organised programme, but
women receive a screen outside of the programme,
rates may also be underreported.
Survival rates are defined in Indicator 4.7 “Screening, survival and mortality for cervical cancer”. See
Indicator 1.5 “Mortality from cancer” for definition,
source and methodology underlying the cancer
mortality rates.
CANCER CARE
•
4.8. SCREENING, SURVIVAL AND MORTALITY FOR BREAST CANCER
4.8.1. Mammography screening, percentage of women
aged 50-69 screened, 2000 to 2010 (or nearest year)
2000
2010
1997-2002
1
Finland
Slovenia1
Netherlands1
Austria 2
Denmark1
United Kingdom1
Spain 2
Belgium 2
Ireland1
Estonia1
Cyprus 2
Italy1
Poland1
EU25
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France 1
Germany1
Greece 2
Czech Republic1
Hungary1
Switzerland 2
Latvia 2
Malta 2
Bulgaria 2
Slovak Republic1
Romania 2
2004-09
85.5
France
83.5
87.0
85.1
80.5
82.1
Finland
84.2
86.3
80.2
Belgium
73.7
75.3
73.4
86.2
83.1
86.0
Sweden
73.3
82.7
Malta
72.7
79.5
84.4
Netherlands
71.6
62.0
74.5
Germany
59.4
59.2
83.3
76.9
EU11
82.5
57.1
Portugal
56.5
53.8
56.1
82.0
76.2
Denmark
82.0
54.5
81.3
79.3
81.2
Austria
49.5
26.7
75.0
United Kingdom
54.3
49.5
72.3
Ireland
49.1
80.3
44.8
70.8
Czech Republic
41.7
31.2
78.6
67.9
Slovenia
76.9
21.9
6.9
Latvia
16.0
73.0
8.0
Norway1
Iceland1
Turkey1
72.6
79.2
Iceland
14.8
25
50
82.4
86.5
Norway
61.0
60.0
0
1. Programme.
4.8.2. Breast cancer five-year relative survival rate,
75
100
Women screened (%)
86.3
0
2. Survey.
20
40
60
80
100
Survival (%)
1 2 http://dx.doi.org/10.1787/888932705159
1 2 http://dx.doi.org/10.1787/888932705178
4.8.3. Breast cancer mortality, females, 2000 to 2010 (or nearest year)
2000
2010
45.6
50
28.1
27.6
25.5
23.7
19.0
20.0
20.1
24.8
26.8
26.2
25.8
25.5
25.2
25.2
25.0
28.9
33.5
35.0
30.5
33.0
30.5
27.1
24.8
24.5
24.4
24.2
28.3
24.0
26.3
23.6
27.7
23.0
27.6
22.8
23.2
22.6
22.0
21.5
21.1
23.0
21.2
26.7
27.9
21.6
21.1
20.6
22.2
20.0
21.4
19.8
21.9
19.4
23.6
19.1
20
20.5
17.7
30
25
30.7
35
25.9
23.0
40
36.7
45
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1 2 http://dx.doi.org/10.1787/888932705197
109
CANCER CARE
• 4.9. SCREENING, SURVIVAL AND MORTALITY FOR COLORECTAL CANCER
Colorectal cancer is the most commonly diagnosed
form of cancer in Europe, with over 432 000 new cases
diagnosed each year. By 2020, annual incidence is expected
to rise to 502 000 cases (IARC, 2011). The annual incidence
rate varies from 21 new cases per 100 000 population in
Greece to 64 new cases in the Czech Republic. There are
several factors that place certain individuals at increased
risk for the disease, including age, the presence of polyps,
ulcerative colitis, a diet high in fat and genetic background.
Furthermore, males are at higher risk of developing
colorectal cancer than females (IARC, 2011).
The European Council has recommended implementation of population-based primary screening programmes
using the faecal occult blood test (FOBT) for men and
women aged 50-74 years (EC, 2010d). Organised screening
programmes are being introduced or piloted in several
countries and data on screening rates have become
available for some European countries. Figure 4.9.1 shows
colorectal screening rates using the FOBT test. The use of
colonoscopy, which is part of several national policy cancer
screening programmes for those with elevated risk, is not
captured by these data (ECHIM, 2012). Based on survey
data, participation is still relatively low across Europe when
compared to long-standing screening programmes for
cervical and breast cancer (see Indicators 4.7 and 4.8).
Germany is a notable exception where screening rates have
reached nearly 55% of the target population in 2010. The
low rates observed in most countries may not only reflect
the relatively recent implementation of many colorectal
cancer screening programmes, but also the organisation
and objectives of these programmes. The European Cancer
Observer has previously noted that there was considerable
variation in the way colorectal cancer screening programmes have been implemented across EU member
states (von Karsa et al., 2008).
Advances in diagnosis and treatment of colorectal
cancer have increased survival over the last decade. There is
compelling evidence in support of the clinical benefit of
improved surgical techniques, radiation therapy and
combined chemotherapy. Figure 4.9.2 shows the five-year
relative survival rate following colorectal cancer diagnosis
between 1997-2002 and 2004-09. In the 2004-09 period, the
110
highest survival rate was observed in Belgium, at nearly 65%.
The figures indicate that survival rates improved in all
eleven countries for which survival data was available for
both periods, with countries such as Slovenia, the Czech
Republic and Germany witnessing substantial gains in
survival rates.
Mortality rates reflect the effect of cancer care, screening
and diagnosis as well as changes in incidence (Dickman and
Adami, 2006). Between 2000 and 2010, average EU mortality
rates fell from 22.2 to 20.5 per 100 000 population, although
the trend was not uniform across all countries. Figure 4.9.3
reveals that out of 25 EU member states for which data were
available, 15 countries saw a decrease whereas ten countries
saw an increase in colorectal cancer mortality. It is noteworthy that the Czech Republic and Germany reported
substantial declines in mortality rates and also have the
highest screening rates in the European Union. Despite a
decrease in their mortality rates for colorectal cancer over the
past decade, Hungary continues to have the highest mortality
rate for colorectal cancer, followed by the Slovak Republic and
the Czech Republic. The number of annual deaths in Europe
due to colorectal cancer is expected to rise from 212 000
in 2008 to 248 000 in 2020 (IARC, 2011).
Colorectal screening rates reflect the proportion of
persons, aged 50-74, who have undergone a colorectal
cancer screening test (faecal occult blood test) in the
last two years. Screening rates are based on selfreported responses to the European Health Interview
Survey (EHIS) and national health interview surveys.
Survival rates are defined in Indicator 4.7 “Screening, survival and mortality for cervical cancer”. See
Indicator 1.5 “Mortality from cancer” for definition,
source and methodology underlying the cancer
mortality rates. Deaths from colorectal cancer are
classified to ICD-10 Codes C18-C21.
CANCER CARE
•
4.9. SCREENING, SURVIVAL AND MORTALITY FOR COLORECTAL CANCER
4.9.1. Colorectal screening, percentage of people
screened aged 50-74, 2010 (or nearest year)
Germany
4.9.2. Colorectal cancer, five-year relative survival rate,
1997-2002
54.2
Czech Republic
Belgium
25.3
France
18.6
Latvia
64.7
60.8
Malta
20.8
Slovak Republic
2004-09
Austria
57.1
France
58.5
63.1
13.7
EU15
Finland
58.9
61.8
Netherlands
57.9
61.0
Sweden
57.3
60.7
12.7
Bulgaria
11.4
Belgium
8.8
Slovenia
5.9
Cyprus
Greece
51.8
EU10
4.8
Portugal
4.3
Slovenia
Hungary
53.3
60.4
Germany
57.4
57.4
45.5
55.8
50.1
Denmark
3.8
55.5
48.1
United Kingdom
Spain
53.3
3.5
49.0
52.9
Ireland
Poland
3.5
41.1
Czech Republic
Malta
49.6
2.6
Latvia
Romania
38.6
1.9
57.0
Norway
Turkey
63.1
Iceland
3.2
0
20
66.1
0
40
60
% of people screened
25
50
75
Note: Data based on surveys in all countries.
Source: Eurostat Statistics Database (based on ECHI).
1 2 http://dx.doi.org/10.1787/888932705216
100
Survival (%)
1 2 http://dx.doi.org/10.1787/888932705235
4.9.3. Colorectal cancer mortality, 2000 to 2010 (or nearest year)
2000
2010
18.0
17.1
16.6
18.8
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22.1
25.3
28.1
26.5
23.8
20.6
22.3
21.3
22.3
20.5
21.6
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20.3
21.8
21.9
21.4
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20.7
21.1
20.3
20.5
20.0
20.6
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15.5
22.2
20.5
19.5
23.7
19.3
20.8
19.1
20.8
18.4
17.7
18.6
17.0
17.8
17.2
19.2
16.8
14.9
13.1
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12.0
12.1
15
16.4
20
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18.6
16.6
22.2
23.7
30
25.4
25.6
28.0
35
28.2
29.0
32.7
34.4
36.1
40
38.5
45
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1 2 http://dx.doi.org/10.1787/888932705254
111
CARE FOR COMMUNICABLE DISEASES • 4.10. CHILDHOOD VACCINATION PROGRAMMES
All EU member states have established childhood
vaccination programmes. All programmes include vaccinations against diseases such as pertussis, diphtheria, tetanus and measles. Reviews of the evidence supporting the
efficacy of vaccines against these diseases have concluded
that the respective vaccines are safe and highly effective.
For example, Peltola et al. (1994) reported that 12 years after
the introduction of a comprehensive national vaccination
programme in Finland measles had virtually been eradicated. Numerous studies have also shown that childhood
vaccines can be highly cost-effective (e.g. Beutels and Gay,
2003; Banz et al., 2003; Lieu et al., 1994).
Figures 4.10.1 and 4.10.2 show that the overall vaccination of children against diphtheria, tetanus and pertussis
(whooping cough) as well as measles is generally high in
European countries. In the European Union, more than 93%
of children aged around 1 year receive the recommended
vaccinations for these diseases. Whilst most countries
have been able to increase or maintain their rate of
childhood vaccinations over the last twenty years, some
countries such as Austria and Denmark have witnessed a
decline in coverage for diphtheria, tetanus and pertussis
(see Indicator 1.11 for more information on pertussis
notifications).
The European Centre for Disease Control (ECDC) reports
that Europe has not met its target of eliminating measles
by 2010. Measles is a highly infectious disease that can lead
to serious complications and, in rare cases, death. Compared
to the five years prior, the numbers of measles cases were
high in 2010 and 2011 with 30 265 and 30 567 cases, respectively. In 2010, the outbreak in the Roma community in
Bulgaria accounted for most of the cases and in 2011, France
accounted for 50% of cases. The ECDC argues that efforts to
increase and maintain vaccination coverage at a high level
will need to be strengthened in order to achieve the renewed
target for eliminating measles by 2015 in the WHO European
Region (ECDC, 2011).
In 2009, there were 5 837 confirmed cases of hepatitis B
virus infection reported in the European Union and EEA/EFTA
member states. With 1.3 notifications per 100 000 population
in EU member states, infection with the hepatitis B virus is
relatively uncommon, but can cause acute or long-term
illness, which is sometimes fatal (see Indicator 1.11 for more
information on hepatitis B notifications). A vaccination for
112
hepatitis B has been available since 1982 and is considered to
be 95% effective in preventing infection and its chronic
consequences, such as cirrhosis and liver cancer. The WHO
recommends that hepatitis B be part of national infant
immunisation programme, or in countries with low levels of
hepatitis B that routine hepatitis B vaccination should still be
given high priority (WHO, 2004c). Figure 4.10.3 shows that
the average percentage of children aged around 1 year who
are vaccinated for hepatitis B across countries with national
programmes is 95%. Countries such as Belgium, Germany and
Turkey have been able to expand coverage in a relatively short
period of time. Between 2000 and 2010, these countries
increased coverage from less than 70% to 90% and more.
A number of countries do not currently require
children to be vaccinated against hepatitis B, or do not have
routine programmes and consequently the rates for these
countries are significantly lower compared to other
European countries. For example, in Sweden, vaccination
against hepatitis B is not part of the general vaccination
programme, and is only recommended to specific risk
groups. In France, hepatitis B vaccination has been controversial but vaccination coverage among children has
increased in recent years. Alongside the systematic introduction of hepatitis B vaccinations in many countries,
there has been decreasing trend of hepatitis B cases, with
EU-wide surveillance showing a fall of 17% in the number
of cases between 2006 and 2009 (ECDC, 2011).
Vaccination rates reflect the percentage of children at
either age 1 or 2 who receive the respective vaccination
in the recommended timeframe. Childhood vaccination
policies differ slightly across countries. Thus, these
indicators are based on the actual policy in a given
country. Some countries administer combination
vaccines (e.g. DTP for diphtheria, tetanus and pertussis)
while others administer the vaccinations separately.
Some countries ascertain vaccinations based on surveys
and others based on encounter data, which may
influence the results.
CARE FOR COMMUNICABLE DISEASES
4.10.1. Vaccination rates for diphteria, tetanus
and pertussis, children aged around 1, 2010
Cyprus
Luxembourg
Belgium
France
Greece
Poland
Slovak Republic
Czech Republic
Finland
Hungary
Portugal
Sweden
Netherlands
Spain
Romania
United Kingdom
Slovenia
Italy
EU27
Lithuania
Ireland
Bulgaria
Estonia
Germany
Denmark
Latvia
Austria
Malta
4.10. CHILDHOOD VACCINATION PROGRAMMES
4.10.2. Vaccination rates for measles,
children aged around 1, 2010
Greece
Hungary
Finland
Czech Republic
Slovak Republic
Poland
Bulgaria
Sweden
Portugal
Lithuania
Germany
Luxembourg
Netherlands
Slovenia
Estonia
Romania
Spain
Belgium
EU27
United Kingdom
Latvia
Italy
France
Ireland
Cyprus
Denmark
Austria
Malta
99
99
99
99
99
99
99
99
99
99
98
98
97
97
97
96
96
96
95
95
94
94
94
93
90
89
83
76
99
99
98
98
98
98
97
96
96
96
96
96
96
95
95
95
95
94
93
93
93
90
90
90
87
85
76
73
FYR of Macedonia
Turkey
Croatia
Serbia
Iceland
Norway
Switzerland
Montenegro
96
Turkey
Iceland
Croatia
Switzerland
FYR of Macedonia
Montenegro
Norway
Serbia
•
96
96
95
95
94
93
91
0
50
100
% of children vaccinated
98
97
95
95
93
93
90
90
0
Source: OECD Health Data 2012 (based on WHO/UNICEF data).
1 2 http://dx.doi.org/10.1787/888932705273
50
100
% of children vaccinated
1 2 http://dx.doi.org/10.1787/888932705292
4.10.3. Vaccination rates for hepatitis B, children aged around 1, 2010
Required and/or routine immunisation
Not required and/or not routinely provided by age 2
95
%
100
80
27
89
90
90
94
97
42
83
89
90
94
94
94
94
40
95
95
96
96
97
97
97
98
98
99
99
60
20
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Note: OECD average only includes countries with required or routine immunisation.
1 2 http://dx.doi.org/10.1787/888932705311
113
CARE FOR COMMUNICABLE DISEASES • 4.11. INFLUENZA VACCINATION FOR OLDER PEOPLE
Influenza is a common infectious disease and affects
people of all ages. WHO Europe reports that each year
seasonal influenza affects between 5 to 15% of the population
in the northern hemisphere. Most people with the illness
recover quickly, but elderly people and those with chronic
medical conditions are at higher risk of complications and
even death. In any particular year, influenza can have a substantial impact on the health of the population and the health
care system (Nicholson et al., 2003; Simonsen et al., 2000).
Vaccines have been used for more than 60 years, and
provide a safe and effective means of preventing influenza,
and reducing the impact of epidemics. Among the elderly,
appropriate influenza vaccines will, in general, reduce the
risk of serious complications or death by 70-85% (Ryan,
2006). In 2003, all World Health Assembly (WHA) countries,
including all EU member states, committed to the goal of
attaining vaccination coverage of the elderly population of at
least 50% by 2006 and 75% by 2010 (WHA, 2003; Mereckiene
et al., 2008).
Figure 4.11.1 shows that around 2010, across 22 EU
member states for which data was available, the average
influenza vaccination rate for people aged 65 and over was
45.3%. Vaccination rates across Europe range from 1% in
Estonia to 74% in the Netherlands. Whilst there is still some
uncertainty about the reasons for the cross-national differences in vaccination rates, studies have highlighted that
the lack of public health insurance coverage may be an
important determinant in explaining low uptake in some
countries (Mereckiene et al., 2008; Kroneman et al., 2003;
Kunze et al., 2007). Studies have also shown that personal
contact with a doctor is a key determinant of uptake, and
that better information through mass-media campaigns,
patient and provider education initiatives, and recall and
reminder systems can play an important role in improving
vaccination rates (Kohlhammer et al., 2007).
Figure 4.11.2 indicates that between 2000 and 2005, vaccination rates across the European Union increased from
45% to 54% of the elderly population but fell between 2005
and 2010. There appears to be no uniform trend across
Europe. Some countries such as France and the Netherlands
have maintained their vaccination rates over the decade,
countries such as Belgium and Portugal have seen a rise in
the rate, and a large number of countries witnessed their
rates increase between 2000 and 2005 but then fall again
in 2010. No country attained the 75% coverage target in 2010.
In late 2009, the Health Ministers of the European Union
114
adopted an EU Council Recommendation to reach the target
of 75% vaccination coverage amongst the elderly as early as
possible and preferably by the 2014-15 winter season. The
recommendation also proposed that the target of 75%
coverage should, if possible, be extended to people with
chronic conditions.
In June 2009, the WHO declared the first influenza
pandemic since 1968-69 (WHO, 2009b). Within 23 weeks of
the first diagnosis of the H1N1 influenza virus (also referred
to as “swine flu”), there were over 53 000 confirmed cases
across all EU member states, Iceland, Liechtenstein and
Norway (ECDC, 2011). The estimated infection attack rates
remained low in the overall population but were high
amongst young people aged 5-19 years. Following the
development, testing and production of a H1N1 vaccine,
most EU member states included the 2009-10 seasonal
influenza vaccine and the pandemic vaccine into their
influenza vaccination programmes (Valenciano et al., 2011).
Despite the worldwide focus on H1N1, numerous studies
have shown that vaccination rates against the virus were
lower than expected in a large number of countries (Poland,
2011; Mereckiene et al., 2012). In part, this may be due to the
easing of concerns about the threat of H1N1 amongst the
general population by the time the vaccine became
available. The most important determinant for individuals
to take-up H1N1 vaccine was previous exposure to
seasonal flu vaccine, leading some researchers to argue
that higher vaccination rates for seasonal flu may help
uptake during potential future pandemics (Poland, 2011;
Nguyen et al., 2011; Bish et al., 2011).
Influenza vaccination rate refers to the number of
people aged 65 and older who have received an
annual influenza vaccination, divided by the total
number of people over 65 years of age. The main
limitation in terms of data comparability arises from
the use of different data sources, whether survey or
programme, which are susceptible to different types
of errors and biases. For example, data from population surveys may reflect some variation due to recall
errors and irregularity of administration.
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24
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17
20
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29
30
35
35
37
37
46
51
59
2005
Sl
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36
39
52
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36.1
46.0
41.4
64.0
65.0
63.8
61.1
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70.3
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56.9
52.2
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45.3
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100
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CARE FOR COMMUNICABLE DISEASES
4.11. INFLUENZA VACCINATION FOR OLDER PEOPLE
%
100
4.11.1. Vaccination rates for influenza, population aged 65 and over, 2010 (or nearest year)
90
10
0
1 2 http://dx.doi.org/10.1787/888932705330
4.11.2. Trends in vaccination rates for influenza, population aged 65 and over, 2000-10 (or nearest year)
2010
90
0
1 2 http://dx.doi.org/10.1787/888932705349
115
© OECD 2012
Chapter 5
Health expenditure and financing
5.1. Coverage for health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
5.2. Health expenditure per capita. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
5.3. Health expenditure in relation to GDP . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
5.4. Health expenditure by function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
5.5. Pharmaceutical expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
5.6. Financing of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
5.7. Trade in health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
117
5.1. COVERAGE FOR HEALTH CARE
Health care coverage enables access to medical goods
and services and provides financial security against
unexpected or serious illness. However, the share of the
population with health insurance coverage – be it public or
private – is an imperfect indicator of accessibility, since the
range of services covered and the degree of cost-sharing
applied to those services vary across countries.
Most European countries have achieved universal (or
near-universal) coverage of health care costs for a core set
of services, which usually include consultations with
doctors, tests and examinations, and hospital care
(Figure 5.1.1). In most countries, dental care and the
purchase of prescribed pharmaceuticals are also at least
partially covered (Paris et al., 2010). Two European countries
do not yet have universal health coverage. In Cyprus, an
estimated 83% of the population are entitled to public
health services, although many currently seek medical care
in the private sector and pay out-of-pocket. A new National
Health Insurance System has been proposed to modernise
public health care and extend coverage (Cyprus National
Reform Programme, 2012; Theodorou et al., 2012). In Turkey,
public coverage has increased rapidly since reforms to
implement universal health insurance began in 2003 under
the ten-year Health Transformation Programme (OECD,
2008b; Tatar et al., 2011). The population covered rose from
70% in 2002 to 83% in 2010 and is continuing to move
towards full coverage estimated to be 98% in 2012.
Basic primary health coverage, whether provided
through public or private insurance, generally covers a
defined “basket” of benefits, in many cases with costsharing. In some countries, additional health coverage can
be purchased through private insurance to cover any costsharing left after basic coverage (complementary insurance), add additional services (supplementary insurance)
or provide faster access or larger choice to providers (duplicate insurance). In most European countries, only a small
proportion of the population has an additional private
health insurance. But in six countries, half or more of
the population had a private health insurance in 2010
(Figure 5.1.2).
118
In France, nearly all the population (96%) has a complementary private health insurance to cover cost-sharing in
the social security system. A large proportion of the population in Belgium, Luxembourg and Slovenia also make use
of complementary health insurance. The Netherlands has
the largest supplementary market (89% of the population),
whereby private insurance pays for prescribed pharmaceuticals and dental care that are not publicly reimbursed.
Duplicate markets, providing faster private-sector access to
medical services where there are waiting times in public
systems, are largest in Ireland (50%). The population
covered by private health insurance has been growing over
the past decade in some countries including France,
Belgium and Germany, but not in Ireland and Luxembourg
(Figure 5.1.3).
The importance of private health insurance is not
linked to a countries’ economic development. Other factors
are more likely to explain market development, including
the history of health care financing arrangements and
government interventions directed at private health insurance markets (OECD, 2004).
Coverage for health care is the share of the population receiving a defined set of health care goods and
services under public programmes and through
private health insurance. It includes those covered in
their own name and their dependents. Public coverage refers both to government programmes, generally
financed by taxation, and social health insurance,
generally financed by payroll taxes. Take-up of private
health insurance is often voluntary, although it may
be mandatory by law or compulsory for employees as
part of their working conditions. Premiums are generally non-income-related, although the purchase of
private cover can be subsidised by the government.
5.1. COVERAGE FOR HEALTH CARE
5.1.1. Health insurance coverage for a core set of services,
Total public coverage
United Kingdom
Sweden
Slovenia
Romania
Portugal
Malta
Lithuania
Latvia
Italy
Ireland
Hungary
Greece
Germany
Finland
Denmark
Czech Republic
Bulgaria
France
Austria
Spain
Belgium
Netherlands
Luxembourg
Poland
Slovak Republic
Estonia
Cyprus
5.1.2. Private health insurance coverage, by type,
Primary private health coverage
Primary
Complementary
Supplementary
Duplicate
100.0
France
100.0
96.0
100.0
Netherlands
100.0
89.0
100.0
100.0
Belgium
100.0
78.9
100.0
Slovenia
100.0
73.1
71.1
100.0
100.0
Luxembourg
55.2
100.0
89.1
10.9
Ireland
100.0
49.8
100.0
Austria
100.0
33.9
100.0
99.9
Germany
99.3
20.2
10.9
31.1
99.2
99.0
Spain
19.7
Portugal
19.6
Denmark
19.6
98.9
97.6
97.5
94.8
93.7
83.0
Switzerland
Serbia
Norway
Montenegro
FYR of Macedonia
Croatia
Iceland
Turkey
100.0
100.0
Switzerland
100.0
29.5
100.0
Turkey
100.0
2.9
100.0
0.2
99.8
Iceland
0.2
82.9
70
80
90
100
Percentage of total population
Source: OECD Health Data 2012; WHO Europe (2012).
1 2 http://dx.doi.org/10.1787/888932705368
0
20
40
60
80
100
Percentage of total population
Note: Private health insurance can fulfil several roles. In Denmark, for
example, it can be both complementary and supplementary.
1 2 http://dx.doi.org/10.1787/888932705387
5.1.3. Trends in private health insurance coverage, 2000 to 2010
Belgium
%
100
France
Germany
Ireland
Luxembourg
80
60
40
20
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
1 2 http://dx.doi.org/10.1787/888932705406
119
5.2. HEALTH EXPENDITURE PER CAPITA
There are large variations in the level and in the rate of
growth of health spending across European countries.
Health expenditure per capita tends to be related with
overall income per capita. Hence, it is not surprising that
Norway and Switzerland are the two European countries
that spent the most on health in 2010, with spending of over
EUR 4 000 per person (Figure 5.2.1). Among EU member
states, the Netherlands (EUR 3 890), Luxembourg (EUR 3 607)
and Denmark (EUR 3 439) were the highest spenders,
exceeding by a wide margin the EU average (EUR 2 171).
Romania and Bulgaria were the lowest spending countries
among EU members. Health spending per capita was also
relatively low in the Former Yugoslav Republic of Macedonia
and Turkey.
Growth in health spending per capita slowed or fell in
real terms in 2010 in almost all European countries, reversing a trend of steady increases in many countries. Health
spending per capita had already started to fall in 2009 in
some countries that were hardest hit by the economic crisis
(e.g. Estonia and Iceland), but this was followed by further
and deeper cuts in 2010. On average across EU member
states, health spending per capita increased by 4.6% per
year in real terms between 2000 and 2009, but this was
followed by a reduction of 0.6% in 2010 (Figure 5.2.2). While
government health spending tended to be maintained at
the start of the economic crisis, cuts in spending really
began to take effect in 2010 in response to budgetary
pressures and the need to reduce large deficits and debts.
In Ireland, cuts in government spending drove total
health spending per capita down by nearly 8% in 2010,
compared with an average growth rate of 6.5% per year
between 2000 and 2009. In Estonia, expenditure on health
per capita dropped by 7.3% in 2010 due to reductions in both
public and private spending, following an average annual
growth rate of 7.2% between 2000 and 2009. In Greece, health
spending per capita fell by 6.7% in 2010, after a yearly growth
rate of 5.7% during the 2000-09 period. In several other
countries (e.g. in Belgium, Finland, the Netherlands, Poland,
the Slovak Republic and Sweden), there was a marked
slowdown in the rate of growth of health spending per
capita, although it remained positive.
Reductions in public spending on health were
achieved through a range of measures. In Ireland, most of
the reductions have been achieved through cuts in wages
and a reduction in the number of healthcare workers as
well as the fees paid to professionals and pharmaceutical
companies. Estonia cut administrative costs in the Ministry
of Health and the prices of publicly-reimbursed health
services. Investment in health infrastructure has also
been put on hold in a number of countries, including the
120
Czech Republic, Estonia, Iceland and Ireland, while gains in
efficiency have been pursued through mergers of hospitals
or accelerating the move from inpatient care in hospital
to outpatient care and day surgery. Other measures have
been introduced to make people pay more out of their
pockets. For example, Ireland increased the share of direct
payments by households for prescribed pharmaceuticals
and appliances, while the Czech Republic increased users’
charges for hospital stays.
As a result of the slowdown or negative growth in
health spending per capita in 2010, the percentage of GDP
devoted to health stabilised or declined slightly in many
EU member states (see Indicator 5.3 “Health expenditure in
relation to GDP”).
Total expenditure on health measures the final
consumption of health goods and services (i.e. current
health expenditure) plus capital investment in health
care infrastructure, as defined in the System of Health
Accounts manual (OECD, 2000; OECD, Eurostat and
WHO, 2011). This includes spending by both public
and private sources on medical services and goods,
public health and prevention programmes, and
administration.
The vast majority of countries now produce health
spending data according to the boundaries and definitions proposed in the System of Health Accounts (SHA)
manual. The comparability of the functional breakdown of health expenditure data has improved over
recent years. However, limitations remain, as some
countries have not yet implemented the SHA classifications and definitions. Even among those countries
that are submitting data according to the SHA, the
comparability of data sometimes needs to be
improved. Different practices regarding the treatment
of capital expenditure and the inclusion of long-term
care in health or social expenditure are some of the
main factors affecting data comparability.
Countries’ health expenditures are converted to a
common currency (Euro) and are adjusted to take
account of the different purchasing power of the
national currencies, in order to compare spending
levels. Economy-wide (GDP) PPPs are used to compare
relative expenditure on health in relation to the rest
of the economy.
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995
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1 758
1 450
1 231
2 524
2 171
2 097
1 783
1 614
2 282
2 244
3 052
2 862
2 504
2 345
3 337
3 058
2 894
2 636
3 439
3 383
4 156
4 056
Capital expenditure
Sw
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0.5
0.4
0.2
0.1
2.7
4.9
4.6
4.1
3.9
3.2
1 000
ov
Ne
Sw
l
ce
ga
an
r tu
-0.2
-0.5
-0.6
-0.9
-2.0
-2.1
6.0
8.9
3 890
3 607
Current expenditure on health
Fr
Po
d
nd
an
la
nl
m
ria
-4.4
-5.0
5.7
2 000
Po
m
us
iu
st
pr
do
lg
Fi
Be
Au
n
24
ai
EU
ng
k
ia
ar
en
Sp
ov
Cy
Ki
Sl
a
ic
ni
bl
nm
pu
-6.7
-7.3
-5
De
Re
ua
ce
5
d
h
th
ee
7.2
6.5
10
i te
ec
Gr
-7.9
3 000
Un
Cz
Li
a
nd
ni
-10
to
la
Ne
t
L u h er
xe l a n
m ds
bo
D e ur g 1
nm
a
Au rk
s
Ge tr ia
rm
an
Fr y
an
Be ce
lg
i
S w um
ed
Un
i t e Ir e e n
d
K i land
ng
do
Fi m
nl
an
d
Sp
ai
n
It a
Gr l y
ee
ce
EU
Po 2 7
r tu
Sl g a l
ov
en
C y ia
p
Sl
ru
ov
s
a M
C z k R alt a
ec ep
h ub
Re lic
pu
Hu blic
ng
a
Po r y
la
Es nd
t
L i oni
th a
ua
ni
La a
Bu t v i a
lg
Ro a r i a
m
an
ia
4 000
Es
Ir e
5.2. HEALTH EXPENDITURE PER CAPITA
5.2.1. Health expenditure per capita, 2010 (or nearest year)
EUR PPPs
5 000
0
1. Health expenditure is for the insured population rather than resident population.
Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Health Expenditure Database.
1 2 http://dx.doi.org/10.1787/888932705425
5.2.2. Annual average growth rate in health expenditure per capita, in real terms,
2000 to 2010 (or nearest year)
Annual average growth rate (%)
15
2009-10
0
1 2 http://dx.doi.org/10.1787/888932705444
121
5.3. HEALTH EXPENDITURE IN RELATION TO GDP
In 2010, EU member states devoted on average
(unweighted) 9.0% of their GDP to health spending in 2010
(Figure 5.3.1), up significantly from 7.3% in 2000, but down
slightly from the peak of 9.2% reached in 2009 following the
economic crisis which started in many countries in the
middle of 2008. In many countries, public spending on
health was maintained in 2009 while GDP was falling
strongly, but this was followed in 2010 by the implementation of a range of measures to reduce government health
spending as part of broader efforts to reduce large budgetary
deficits and debts (see Indicator 5.2).
The Netherlands had the highest share of its GDP
allocated to health in 2010 (12%), followed by France and
Germany (both at 11.6%). This share remains well below the
United States where health expenditure accounted for
17.6% of GDP in 2010. The share of health spending in GDP
was lowest in Romania and Turkey, at around 6%.
With the exception of Cyprus, public funding remains
the main source of financing of health expenditure in all
EU member states, with close to three-quarters of all
spending being paid by public sources (see Indicator 5.6).
The ranking of countries in terms of public expenditure on
health as a share of GDP is not very different from total
expenditure on health. The Netherlands (9.6%) and
Denmark (9.5%) had the highest share of public expenditure on health to GDP, followed by France (9.0%) and
Germany (8.9%). Cyprus had the lowest share of public
spending on health to GDP (3.2%), followed by Bulgaria
(4.0%) and Latvia (4.1%).
For a more complete understanding of the level of
health spending, the health spending to GDP ratio should
be considered together with health spending per capita
(see Indicator 5.2). Countries having a relatively high health
spending to GDP ratio might have relatively low health
expenditure per capita, and the converse also holds. For
example, Belgium and Portugal both spent around 10.5% of
their GDP on health in 2010; however, per capita spending
(adjusted to EUR PPP) was nearly 50% higher in Belgium
(see Figure 5.2.1).
Changes in the ratio of health spending to GDP are the
result of the combined effect of growth in both GDP and
health expenditure. Between 2000 and 2010, the annual
average growth in health expenditure per capita in real
122
terms was about 4% on average in EU member states,
nearly two-times greater than the growth rate in GDP
per capita. With the exception of Bulgaria, Iceland and
Luxembourg, annual growth in health spending outpaced
GDP growth in all European countries over the past decade
(Figure 5.3.2). This explains why the share of GDP allocated
to health increased from 7.3% to 9.0% during that period.
In France and Germany, the health spending to GDP
ratio increased from just over 10% in 2000 to 11.6% in both
countries in 2010 (Figure 5.3.3). Health spending per capita
grew slightly faster in Germany than in France over the past
decade, but so did GDP per capita. The share of GDP was
relatively stable in both countries between 2003 and 2008,
but it then increased by 1 percentage point in 2009 as health
spending continued to grow while GDP fell in both countries.
In the United Kingdom, the health spending share of
GDP used to be below the EU average, but since 2006, it is
now above average. As in many other European countries,
the share of health spending allocated to GDP in the United
Kingdom increased by a full percentage point in 2009
following the financial and economic crisis, but came down
slightly in 2010.
See Indicator 5.2 for the definition of total health
expenditure.
Gross domestic product (GDP) = final consumption
+ gross capital formation + net exports. Final
consumption of households includes goods and
services used by households or the community to
satisfy their individual needs. It includes final
consumption expenditure of households, general
government and non-profit institutions serving
households.
In countries, such as Ireland and Luxembourg,
where a significant proportion of GDP refers to profits
exported and not available for national consumption,
gross national income (GNI) may be a more meaningful measure than GDP.
5.3. HEALTH EXPENDITURE IN RELATION TO GDP
5.3.1. Total health expenditure as a share of GDP, 2010 (or nearest year)
Public
Private
11.4
7.1
7.8
9.3
9.4
9.1
10.4
6.1
6.3
6.0
7.0
6.8
7.2
7.0
7.5
7.4
8
7.8
8.6
7.9
8.9
9.0
9.0
9.0
9.2
9.6
9.3
10
9.6
10.2
9.6
10.7
10.5
11.0
11.6
12
11.1
11.6
12.0
% GDP
14
6
4
2
rm
De any
nm
a
Au rk
st
Po r i a
r tu
Be gal
lg
iu
m
Gr 2
ee
ce
Sp
ai
Un
i te S we n
d
K i den
ng
do
m
It a
Sl
o v Ir e l y
ak la
Re nd
pu
b
Sl lic
ov
en
ia
EU
27
Fi
nl
an
d
Lu
M
xe a l
m ta
bo
u
C z Hu r g 3
ec ng
h
Re ar y
pu
bl
C y ic
pr
Bu us
lg
ar
Po i a
la
Li nd
th
ua
ni
a
La
tv
i
a
Es
to
Ro n i a
m
an
ia
Sw
it z
er
la
n
Se d
rb
No ia
rw
ay
I
M c el a
on
nd
te
ne
FY
gr
R
o f Cr o o
M
ac atia
ed
on
i
Tu a
rk
ey
ce
Ge
an
la
er
th
Ne
Fr
nd
s1
0
1. In the Netherlands, it is not possible to clearly distinguish the public and private share related to investments.
2. Public and private expenditures are current expenditures (excluding investments).
3. Health expenditure is for the insured population rather than resident population.
1 2 http://dx.doi.org/10.1787/888932705463
5.3.2. Annual average growth in health expenditure
and GDP per capita, in real terms,
5.3.3. Total health expenditure as a share of GDP,
2000-10, selected EU member states
France
United Kingdom
Germany
Italy
EU27
Annual average growth in health expenditure per capita (%)
7
LTU
TUR
POL
6
MNE
EST
ROU
NLD
5
IRL
CZE
GBR
GRC
BGR
4
FIN
ESP
EU
SVN
SWE
MLT
3
DNK BEL
HUN
NOR DEU LVA
HRV
CYP
FRA
2
AUT
PRT CHE
ITA
1
LUX
ISL
0
0
1
2
3
4
5
6
7
Annual average growth in GDP per capita (%)
% GDP
12
Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global
1 2 http://dx.doi.org/10.1787/888932705482
1 2 http://dx.doi.org/10.1787/888932705501
10
8
6
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
123
5.4. HEALTH EXPENDITURE BY FUNCTION
In 2010, curative and rehabilitative care provided either
as inpatient care (including day care) or outpatient care,
accounted for 61% of current health spending (excluding
capital investment) on average across EU member states
(Figure 5.4.1). A further 23% of health spending was allocated
to medical goods (including mainly pharmaceuticals, which
accounted for 19% of total health spending), 10% to longterm care and the remaining 6% on collective services
including public health services and administration.
The allocation of spending by type of care varies
significantly across European countries. Spending for
inpatient care, day care and outpatient care depends on the
institutional arrangements for health care provision. In
Portugal and Sweden, for example, the majority of curative
and rehabilitative spending is on outpatient care, with
relatively low levels of hospital inpatient activity. In some
other countries, such as Bulgaria and Romania, inpatient
activity (including day care) plays a more dominant role
accounting for over two-thirds of all curative and rehabilitative care expenditure.
The other major category of health expenditure
is on medical goods, mainly pharmaceuticals (see
Indicator 5.5). In Hungary and the Slovak Republic, expenditure on medical goods is in fact a larger spending
category than inpatient care or outpatient care, representing 37% of current health expenditure. In Norway and
Switzerland, on the other hand, spending on medical goods
represents only 12% of total health spending. Differences in
the consumption pattern of pharmaceuticals and relative
prices play a role in explaining some of the variations
between countries.
There are some large differences between countries in
their expenditure on long-term care. Countries such as
Denmark, the Netherlands and Norway, which have
established formal arrangements for the elderly and the
dependent population, allocate more than 20% of current
health spending to long-term care. In countries with less
comprehensive formal long-term care services such as
Portugal, the expenditure on long-term care accounts for a
much smaller share of total spending.
Figure 5.4.2 compares the real growth rates in inpatient and outpatient spending over the last decade. With
inpatient care being highly labour and capital intensive
and, therefore, expensive, certain high-income countries
with developed health systems have sought to reduce the
share of spending in hospitals by shifting to more outpatient and home based care and improving primary care
to prevent hospital admissions in the first place. In Iceland,
spending on inpatient services decreased by over 3% per
year on average between 2000 and 2010, while outpatient
care grew on average at an annual rate of 3.2%. In other
countries such as the Czech Republic and Poland, spending
for both inpatient and outpatient care increased strongly
124
over the past decade, but the growth in inpatient services
exceeded outpatient care. On average across EU member
states, the growth in inpatient spending was slightly above
the growth in outpatient spending during the past decade.
Figure 5.4.3 shows the share of health expenditure
allocated to organised public health and prevention
programmes. On average, EU member states allocated less
than 3% of their spending on health to prevention activities
such as vaccination programmes and public health
campaigns on alcohol abuse and smoking. However, where
such initiatives are carried out at the primary care level,
such as in Spain, the prevention function might not be
captured separately and may be included under spending
on curative care. Countries adopting a more centralised
approach to public health and prevention campaigns are
better able to identify spending on such programmes.
The System of Health Accounts (OECD, 2000; OECD,
Eurostat and WHO, 2011) defines the boundaries of the
health system. Current health expenditure comprises
personal health care (curative care, rehabilitative care,
long-term care, ancillary services and medical goods)
and collective services (public health services and
health administration). Curative, rehabilitative and
long-term care can also be classified by mode of
production (inpatient, day care, outpatient and home
care). Day care comprises health care services
delivered to patients who are formally admitted to
hospitals, ambulatory premises or self standing centres but with the intention to discharge the patient on
the same day. An outpatient is not formally admitted
to a facility (physician’s private office, hospital outpatient centre or ambulatory-care centre) and does not
stay overnight. Concerning long-term care, only the
health aspect is normally reported as health expenditure. This is the reason why some countries with
comprehensive long-term care packages focusing on
social care might be ranked surprisingly low when
analyzing long-term care expenditure based on
SHA data.
Factors limiting the comparability across countries
include estimations of long-term care expenditure.
Also, expenditure in hospitals may be used as a proxy
for inpatient care services, although hospital expenditure may include spending on outpatient, ancillary,
and in some cases drug dispensing services (Orosz
and Morgan, 2004).
5.4. HEALTH EXPENDITURE BY FUNCTION
5.4.1. Current health expenditure by function of health care, 2010 (or nearest year)
Countries are ranked by inpatient curative care as a share of current expenditure on health
Inpatient (including day care) 1
%
100
6
3
4
8
5
9
Outpatient 2
6
10
7
Long-term care
3
7
5
6
4
7
90
Medical goods
7
9
4
6
11
20
80
17
27
14
21
25
70
60
4
4
9
28
28
24
13
4
10
9
20
16
37
29
11
12
37
50
12
22
37
1
11
20
7
18
24
8
4
3
9
12
16
18
20
24
15
6
10
5
7
12
17
24
23
30
24
24
29
1
37
Collective services
4
20
18
4
28
22
13
28
18
40
34
36
30
27
31
26
42
35
29
45
37
37
27
25
31
33
31
30
28
33
30
20
41
40
38
37
36
35
34
33
32
32
31
31
30
30
29
29
28
28
10
27
26
25
25
21
ak
nd
d
la
an
er
Sw
it z
ay
No
Re
el
rw
bl
pu
Sp
ov
Lu
Ic
ic
n
ai
ar
ga
ng
Hu
Po
xe
y
l
g
ur
bo
m
r tu
en
d
ed
Sw
Fi
nl
an
y
k
an
rm
Ge
De
nm
ar
m
a
iu
lg
ni
Be
a
22
to
Es
EU
ni
bl
ua
th
Sl
Cz
ec
Ne
h
Li
pu
Re
ov
Sl
th
ic
ia
ia
tv
en
s
nd
La
ria
la
er
ce
nd
la
st
Au
Po
us
an
Fr
ia
pr
an
Cy
m
Ro
Bu
lg
ar
ia
0
1. Refers to curative and rehabilitative inpatient and day care provided in hospitals, day surgery clinics, etc.
2. Refers to curative and rehabilitative care in doctors’ offices, clinics, outpatient departments of hospitals, home care and ancillary services.
1 2 http://dx.doi.org/10.1787/888932705520
5.4.2. Growth in inpatient and outpatient expenditure
per capita, in real terms, 2000-10 (or nearest year)
Inpatient1
Outpatient 2
Poland
8.1
5.3
Czech Republic
7.0
4.2
Netherlands
5.7
1.2
Slovenia
4.0
2.7
3.7
Estonia
7.1
Denmark
3.4
2.6
3.3
4.9
Finland
EU15
3.2
3.0
Spain
2.8
2.5
Austria
2.1
1.6
2.0
3.2
Sweden
France
1.9
1.1
1.8
2.7
1.8
2.2
0.7
3.3
0.4
1.1
Hungary
Germany
Portugal
Luxembourg
Norway
2.4
1.4
2.5
Switzerland
-3.1
Iceland
-5
2.6
3.2
0
5
10
Annual average growth rate (%)
1. Including day care.
2. Including home care and ancillary services.
1 2 http://dx.doi.org/10.1787/888932705539
5.4.3. Expenditure on organised public health
and prevention programmes, 2010 (or nearest year)
Romania
Finland
Slovak Republic
Netherlands
Hungary
Slovenia
Sweden
Bulgaria
Germany
Latvia
EU24
Estonia
Czech Republic
Spain
Denmark
Portugal
France
Poland
Belgium
Luxembourg
Austria
Malta
Lithuania
Cyprus
Italy
6.2
5.4
5.3
4.8
4.5
3.8
3.6
3.5
3.2
3.1
2.9
2.7
2.5
2.3
2.3
2.1
2.1
2.1
2.0
1.9
1.8
1.3
0.8
0.5
0.5
Serbia
Norway
Switzerland
Iceland
Croatia
6.3
2.5
2.4
1.5
0.7
0
2
4
6
8
% current expenditure on health
1 2 http://dx.doi.org/10.1787/888932705558
125
5.5. PHARMACEUTICAL EXPENDITURE
Pharmaceutical expenditure accounted for almost a
fifth (19%) of all health expenditure on average in
EU member states in 2010, making it the third biggest
spending component after inpatient and outpatient care.
Increased spending on pharmaceuticals has contributed to
the overall rise in total health expenditure over the past
decade, although the growth rate turned negative in several
countries in 2010. The relationship between pharmaceutical expenditure and other health expenditure is a
complex one, in that increased expenditure on pharmaceuticals to tackle different diseases may reduce the need
for costly hospitalisations and interventions now or in the
future.
The total pharmaceutical bill across the European Union
reached more than EUR 190 billion in 2010. However, there are
wide variations in pharmaceutical spending per capita across
countries, reflecting differences in volume, structure of
consumption and pharmaceutical prices (Figure 5.5.1, left
panel). At EUR 528, Ireland spent more on pharmaceuticals
than any other European country on a per capita basis. This is
50% above the average across EU member states of EUR 349.
Other countries with relatively high pharmaceutical expenditure include Germany (EUR 492), Belgium (EUR 479) and
France (EUR 468). At the other end of the scale, Romania spent
only EUR 164 per capita. Denmark, Estonia, Latvia and Poland
are also among the countries that have relatively low
pharmaceutical spending per capita, at less than 70% of the
EU average.
Pharmaceutical spending accounted for 1.6% of GDP
on average across EU member states, ranging from below
1% in countries such as Denmark, Luxembourg and
Norway, to more than 2% in Bulgaria, Hungary, the Slovak
Republic and Serbia (Figure 5.5.1, right panel).
The economic crisis in many European countries has
had a significant effect on pharmaceutical spending
(Figure 5.5.2). Between 2000 and 2009, pharmaceutical
spending increased on average in EU member states by
3.2% per year in real terms (slightly below the growth rate
in total health spending), but the average growth in
pharmaceutical spending in 2010 came to a halt (0.0%). In
Ireland, pharmaceutical spending per capita increased
at a rate of over 8% per year in real terms on average
126
between 2000 and 2009, but the growth rate slowed down
markedly to less than 2% in 2010. This slowdown followed
the introduction of a series of measures to control pharmaceutical spending in Ireland, including large price reductions and increases in co-payments by households. Several
other countries severely affected by the economic crisis cut
their spending on pharmaceuticals drastically in 2010:
Iceland (–6.3%), Lithuania (–4.6%) and Portugal (–3.3%).
Many European countries have attempted to control
pharmaceutical expenditures even before the recession via
a mix of price and volume controls directed at physicians
and pharmacies, as well as policies targeting specific products (OECD, 2010b). In Germany, pharmaceutical companies must now enter into rebate negotiations with health
insurance funds for new innovative medicines, putting an
end to the previous free-pricing regime. Spain mandated a
price reduction for generics and introduced a general
rebate applicable for all medicines prescribed by NHS
physicians in 2010. In France, price reductions or rebates on
pharmaceuticals have often been used as adjustment
variables to contain health spending growth while in the
United Kingdom caps were introduced on pharmaceutical
companies’ profits relating to NHS sales.
Pharmaceutical expenditure covers spending on prescription medicines and self-medication, often referred
to as over-the-counter products. In some countries, the
data also include other medical non-durable goods
(adding approximately 5% to the spending). The expenditure also includes pharmacists’ remuneration when
the latter is separate from the price of medicines.
Pharmaceuticals consumed in hospitals are excluded
(their inclusion would add another 15% to pharmaceutical spending approximately). Final expenditure on
pharmaceuticals includes wholesale and retail margins
and value-added tax.
5.5. PHARMACEUTICAL EXPENDITURE
5.5.1. Expenditure on pharmaceuticals per capita and as a share of GDP, 2010 (or nearest year)
Prescribed
Over-the-counter
Public
Pharmaceutical expenditure per capita
Pharmaceutical expenditure as a share of GDP
Ireland1
Germany
Belgium
France
Slovak Republic1
Hungary1
Spain
Austria
Italy1
Portugal1
Netherlands1
EU25
Sweden
Finland
Slovenia
Cyprus
Luxembourg1
Bulgaria 2
United Kingdom1
Czech Republic
Lithuania1
Poland
Denmark
Estonia
Latvia
Romania1
528
492
479
468
427
414
399
396
393
391
370
349
343
340
336
322
317
291
289
274
257
237
229
210
175
164
1.7
1.7
1.7
1.9
2.4
2.6
1.8
1.3
1.6
2.0
1.1
1.6
1.2
1.2
1.8
1.3
0.6
2.8
1.0
1.5
1.9
1.6
0.8
1.4
1.5
1.4
Switzerland
Iceland
Norway1
Serbia 2
393
327
305
279
600
EUR PPP
400
Private
200
1.1
1.5
0.7
3.3
0
0
1
2
3
4
% GDP
1. Includes medical non-durables.
2. Total medical goods.
1 2 http://dx.doi.org/10.1787/888932705577
5.5.2. Average annual growth in pharmaceutical expenditure per capita, in real terms, 2000 to 2010 (or nearest year)
2000-09
2009-10
2.5
2.3
1.2
2.2
1.8
1.8
1.9
2.1
3.1
3.4
0.2
0.2
1.4
1.8
2.4
3.2
3.4
2.4
1.3
1.3
1.5
2.3
3.1
3.8
4.1
5
4.6
5.7
9.3
7.9
8.6
10
-0.2
-3.1
-3.3
-6.3
-4.6
-5
-1.3
-0.1
0.0
0.0
-0.6
-0.6
-1.0
-1.2
-1.2
-1.3
-1.8
-1.8
-1.4
0
ay
rw
nd
la
er
it z
Ic
el
Sw
No
d
an
y
Hu
ng
ar
ia
ia
an
m
Ro
pr
en
Sl
ov
us
ic
bl
pu
Re
ak
ov
Cy
y
an
nd
Sl
la
rm
Ge
s
nd
la
er
th
Ne
Ir e
en
ce
ed
Sw
20
an
Fr
nd
la
EU
n
ai
Po
Sp
k
ar
nm
De
iu
m
ly
It a
lg
Be
ria
d
an
st
Au
nl
bl
pu
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Re
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Fi
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ga
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Po
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1 2 http://dx.doi.org/10.1787/888932705596
127
5.6. FINANCING OF HEALTH CARE
All European countries use a mix of public and private
financing to pay for health care. In some countries, public
purchasing of health care is generally confined to the use
of government revenues. In others where there is social
insurance, public financing uses these social contributions, in
addition to any general government revenues. Private financing of health care consists of payments by households (either
as stand-alone payments or co-payments) as well as various
forms of private health insurance intended to replace,
complement or supplement publicly financed coverage. In
addition, occupational health care may be directly provided
by employers, and other health care benefits may be provided
by charities and other non-government organisations.
The public sector is the main source of health
care financing in all European countries, except Cyprus
(Figure 5.6.1). In 2010, on average in the European Union,
73% of health care was publicly financed. Public financing
accounted for over 80% in the Netherlands, the Nordic
countries (except Finland), Luxembourg, the Czech Republic,
the United Kingdom and Romania. The share was the lowest
in Cyprus (43%), and Bulgaria, Greece and Latvia (55-60%).
The economic crisis has had an effect on the mix of
public and private health financing as public spending has
been contained or cut in many countries severely affected
by the recession. In Ireland, the share of public spending
decreased by nearly 6 percentage points between 2008
and 2010 and stands now at 70%. Substantial falls have also
been observed in the Slovak Republic and Bulgaria. On the
other hand, some countries saw their public spending
share rise since 2008, including Cyprus and Norway.
Although public funding is the main source of funds
for health spending in nearly all European countries, this
does not imply that the public sector plays the dominant
financing role for all health services and goods. Figure 5.6.2
shows the shares of financing for medical services and
medical goods separately. On average across the European
Union, the public sector covers a much higher proportion of
the costs of medical services compared with medical goods
(comprising mainly pharmaceutical products). Over 80% of
the costs of health care services are covered by public
funds compared with just over 50% for medical goods. In
Romania, public funding covers more than 90% of expenditure on medical services, but only about 40% of spending
on medical goods. Germany, Luxembourg and the
Netherlands are the only countries where public spending
coverage for medical goods exceeds 70%.
After public financing, the main source of funding for
health expenditure is out-of-pocket payments. In 2010, the
share of out-of-pocket payments was highest in Cyprus,
Bulgaria and Greece. It was the lowest in the Netherlands
(6%), France (7%) and the United Kingdom (9%). The share of
out-of-pocket spending has increased over the past decade
in about half of EU member states while it has decreased in
128
the other half. The Slovak Republic has seen the biggest
increase in the share of health spending paid directly
by households, with a rise of over 15 percentage points
between 2000 and 2010. This increase is due to a rise in
co-payments on prescribed pharmaceuticals, higher spending by households on non-prescribed medicines, increased
use of private providers and informal payments to public
providers (Szalay et al., 2011). The share of out-of-pocket
payments has also increased substantially in Bulgaria,
Cyprus and Malta. In some countries hard hit by the economic crisis, the public coverage for certain services has
been reduced in recent years, with a growing share of payments being transferred to households. In Iceland, the share
of out-of-pocket spending has increased by 2.2 percentage
points between 2008 and 2010, although this has not totally
offset the previous reduction in this share between 2000
and 2008. In Ireland, the share of out-of-pocket spending
increased by 1.7 percentage points between 2008 and 2010,
and is now 2.1 percentage points greater than in 2000.
On the other hand, some other countries have
extended public coverage for health services in recent
years to improve access to care, resulting in a lower share
of health spending paid directly by households. Turkey is
the most striking example; it has moved since 2003 to
extend public coverage for health services for a larger
proportion of the population (see Indicator 5.1), with public
funding now accounting for 73% of total health spending,
equal to the EU average. This has led to a reduction of
nearly 10 percentage points in the share of direct payments
by households over the past decade. The share of
out-of-pocket payments has also come down substantially
in Poland and Switzerland, although it still remains slightly
above the EU average.
There are three elements of health care financing:
sources of funding (households, employers and the
state), financing schemes (e.g. compulsory or voluntary
insurance), and financing agents (organisations managing financing schemes). Here “financing” is used in the
sense of financing schemes as defined in the System of
Health Accounts (OECD, 2000; OECD, Eurostat and WHO,
2011). Public financing includes general government
revenues and social security funds. Private financing
covers households’ out-of-pocket payments, private
health insurance and other private funds (NGOs and
private corporations). Out-of-pocket payments are
expenditures borne directly by the patient. They include
cost-sharing and, in certain countries, estimations of
informal payments to health care providers.
5.6. FINANCING OF HEALTH CARE
5.6.1. Expenditure on health by type of financing, 2010 (or nearest year)
Public
% of total expenditure on health
100
2
0
3
90
5
6
13
15
12
0
0
17
19
Private out-of-pocket
1
0
5
3
9
18
5
9
2
6
19
20
4
17
80
19
13
7
21
2
1
1
13
14
19
Private insurance
27
13
4
22
13
17
26
2
1
Other
0
1
6
14
2
9
15
18
19
32
26
26
38
36
30
36
38
64
62
25
43
70
49
60
50
40
86
85
84
84
83
81
80
86
80
79
77
77
77
76
75
74
73
73
30
72
72
70
85
80
73
66
65
65
64
60
59
67
65
55
43
20
10
Ne
th
No
er
la
n
De ds 1
L u nm
C z xem ar k
ec bo
U n h R ur g
i te epu
d
K i blic
ng
do
Sw m
ed
Ro e n
m
an
ia
It a
l
Es y
to
n
Au ia
st
ria
1
Fr
a
Ge nc e
rm
Be any
lg
iu
m1
Fi
nl
an
d
Sp
Sl a in
ov
en
ia
EU
Li 2 7
th
ua
n
Po i a
la
n
Ir e d
la
Po nd
r tu
ga
l
M
a
lt a
Sl
H
ov un
ak ga
Re r y
pu
bl
ic
La
tv
i
Gr a
ee
Bu c e
lg
ar
C y ia
pr
us
rw
a
Cr y
oa
t
Ic i a
el
an
T d
M ur k
on ey
1
te
F Y Sw neg
R it ze ro
of
r
M lan
ac d 1
ed
on
i
Se a
rb
ia
0
1. Data refer to current expenditure.
Source: OECD Health Data 2012; WHO Global Health Expenditure Database.
1 2 http://dx.doi.org/10.1787/888932705615
5.6.2. Public share of expenditure on medical services
and goods, 2010 (or nearest year)
Medical services
Romania
Czech Republic
Netherlands
Estonia
Denmark
Italy
Sweden
Lithuania
France
Poland
Luxembourg
Finland
Austria
EU23
Slovenia
Germany
Belgium
Spain
Bulgaria
Slovak Republic
Hungary
Portugal
Latvia
Cyprus
Medical goods
92.6
39.8
91.5
59.8
90.5
71.0
88.6
50.2
88.6
51.6
87.2
48.4
87.0
54.0
86.8
35.6
85.2
61.2
83.8
39.8
83.0
77.5
81.7
45.6
81.0
61.9
80.5
51.5
80.5
49.9
70.2
77.0
63.9
77.0
64.1
76.4
20.5
74.8
59.0
74.4
48.3
55.4
71.2
69.2
33.6
45.1
22.1
Norway
Iceland
Serbia
Switzerland
79.1
89.1
57.6
86.9
48.8
77.9
31.7
0
25
65.1
66.9
50
75
100
% total expenditure on function
1 2 http://dx.doi.org/10.1787/888932705634
5.6.3. Change in share of out-of-pocket spending
in total health spending, 2000 to 2010 (or nearest year)
Slovak Republic
Bulgaria
Cyprus
Malta
Czech Republic
Romania
Ireland
Germany
Portugal
Slovenia
Greece
EU27
Sweden
France
Hungary
Luxembourg
Belgium1
Austria1
Estonia
Denmark
United Kingdom
Finland
Netherlands1
Spain
Latvia
Lithuania
Italy
Poland
15.3
6.4
5.9
5.6
5.2
4.4
2.1
1.7
1.7
1.1
0.6
0.3
0.2
0.2
-0.1
-0.2
-0.6
-1.0
-1.4
-1.5
-2.5
-3.1
-3.9
-3.9
-4.4
-4.7
-6.7
-7.9
Serbia
Montenegro
Croatia
Iceland
Norway
FYR of Macedonia
Switzerland1
Turkey1
11.2
1.7
0.7
-0.8
-1.7
-6.2
-7.8
-9.7
-15
-10
-5
0
5
10
15
20
Percentage points
1. Data refer to current expenditure.
Source: OECD Health Data 2012; WHO Global Health Expenditure Database.
1 2 http://dx.doi.org/10.1787/888932705653
129
5.7. TRADE IN HEALTH SERVICES
Trade in health services and its most high-profile
component, medical tourism, has attracted a great deal of
media attention in recent years. The growth in “imports” and
“exports” has been fuelled by a number of factors. Technological advances in information systems and communication
allow patients or third party purchasers of health care to seek
out quality treatment at lower cost and/or more immediately
from health care providers in other countries. An increase in
the portability of health cover, whether as a result of regional
arrangements with regard to public health insurance
systems, or developments in the private insurance market,
are also poised to further increase patient mobility. All this is
coupled with a general increase in the temporary movement
of populations for business, leisure or specifically for medical
purposes between countries.
While the major part of international trade in health
services does involve the physical movement of patients
across borders to receive treatment, to get a full measure of
imports and exports, there is also a need to consider goods
and services delivered remotely such as pharmaceuticals
ordered from another country or diagnostic services
provided from a doctor in one country to a patient in
another. The magnitude of such trade remains small, but
advances in technology mean that this area also has the
potential to grow rapidly.
Data on imports of health services and goods are
available for most European countries and amounted to
more than EUR 3 billion in 2010. The vast majority of this
trade is between European countries. However, due to data
gaps and under-reporting, this is likely to be a significant
underestimate. With health-related imports reaching
nearly EUR 1 500 million, Germany is by far the greatest
importer in absolute terms, followed by the Netherlands
and France. Nevertheless, in comparison to the size of the
health sector as a whole, trade in health goods and services
remains marginal for most countries. Even in the case of
Germany, reported imports represent only around 0.5% of
Germany’s health expenditure. The share rises above 1% of
health spending only in Cyprus and Iceland, as these
smaller countries see a higher level of cross-border movement of patients. Luxembourg is a particular case because
a large part of its insured population is living and consuming health services in neighbouring countries.
A smaller number of countries report total exports of
health-related travel expenditure and other health services,
130
totalling around EUR 2.5 billion in 2010 (Figure 5.7.2). For
many countries these figures are, again, likely to be significant underestimates. In absolute values, the Czech Republic
and France reported exports in excess of EUR 400 million,
while the exports of Turkey, Poland and the United Kingdom
exceeded EUR 200 million. In relation to overall health
spending, health-related exports remain marginal in most
countries, except in the Czech Republic and Croatia where
they equate to 4.2% and 2.8% of overall health spending.
These countries have become popular destinations for
patients from other European countries, particularly for
services such as dental surgery. The growth rate in healthrelated exports has exceeded 20% per year over the past five
years in the Czech Republic.
Patient mobility in Europe may see further growth as a
result of an EU directive adopted in 2011 which supports
patients in exercising their right to cross border health care
and promotes co-operation between health systems
(Directive 2011/24/EU).
The System of Health Accounts includes imports
within current health expenditure, defined as
imports of medical goods and services for final
consumption. Of these the purchase of medical
services and goods, by resident patients while abroad,
is currently the most important in value terms.
In the balance of payments, trade refers to goods
and services transactions between residents and
non-residents of an economy. According to the
Manual on Statistics of International Trade in Services,
“Health-related travel” is defined as “goods and
services acquired by travellers going abroad for
medical reasons”. This category has some limitations
in that it covers only those persons travelling for the
specific purpose of receiving medical care, and does
not include those who happen to require medical
services when abroad. The additional item “Health
services” covers those services delivered across
borders but can include medical services delivered
between providers as well as to patients.
5.7. TRADE IN HEALTH SERVICES
5.7.1. Imports of health care services as share of total health expenditure, 2010 and annual growth rate in real terms,
Annual growth rate in real terms, 2005-10
2010
Luxembourg
Cyprus1
Portugal
Netherlands
Bulgaria1
Belgium1
Germany
Hungary
Latvia
Austria
Slovak Republic
Slovenia
France 1
Italy1
Czech Republic
Sweden
Lithuania
Estonia
Denmark
United Kingdom1
Poland
Greece 1
Ireland1
Romania
8.60 ||
2.47
0.91
0.81
0.81
0.60
0.52
0.30
0.29
0.28
0.22
0.21
0.19
0.17
0.15
0.13
0.12
0.11
0.08
0.08
0.07
0.06
0.06
0.04
0.60
0.40
0.14
1
7.4
3.1
-2.7
29.8
-11.3
9.3
17.7
-6.3
24.2
31.1
13.5
1.2
17.9
1.8
11.1
|| 62.7
-1.9
-3.4
7.9
4.9
-5.5
0.8
30.9
Iceland
Croatia1
Turkey1
Norway
1.09
3
2
% of total health expenditure
-7.7
0
12.2
-0.5
5.3
-3.9
-20
0
20
40
Annual growth rate (%)
1. Refers to balance of payments concept of health-related travel and health services of personal, recreational and cultural services.
Source: OECD Health Data 2012 and OECD-Eurostat Trade in Services Database.
1 2 http://dx.doi.org/10.1787/888932705672
5.7.2. Exports of health-related travel or other services as share of total health expenditure,
2010 and annual growth rate in real terms, 2005-10 (or nearest year)
Annual growth rate in real terms, 2005-10
2010
Czech Republic
Luxembourg
Hungary
Slovenia
Poland
Estonia
Belgium
Cyprus
Latvia
Bulgaria
Lithuania
Austria
France
Sweden
United Kingdom
Greece
Italy
Romania
Slovak Republic
4.17
1.38
1.19
1.00
0.93
0.87
0.77
0.72
0.70
0.58
0.46
0.36
0.18
0.17
0.13
0.13
0.12
0.11
0.08
0.88
2
24.8
-14.5
16.9
9.5
9.5
-17.5
-8.4
22.7
12.9
4.0
6.4
-3.6
-22.4 ||
12.7
-12.1
-0.1
-3.8
-13.4
Croatia
Turkey
2.75
6
4
% of total health expenditure
21.3
0
2.7
-6.8
-20
0
20
40
Annual growth rate (%)
Note: Health-related exports occur when domestic providers supply medical services to non-residents.
Source: OECD-Eurostat Trade in Services Database.
1 2 http://dx.doi.org/10.1787/888932705691
131
© OECD 2012
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142
ANNEX A
ANNEX A
Additional information on demographic
and economic context
Table A.1. Total population, mid-year, thousands, 1960 to 2010
Austria
Belgium
Bulgaria
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Germany1
Greece
Hungary
Ireland
Italy
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Poland
Portugal
Romania
Slovak Republic
Slovenia
Spain
Sweden
United Kingdom
EU
Croatia
FYR of Macedonia
Iceland
Montenegro
Norway
Serbia
Switzerland
Turkey
1960
1970
1980
1990
2000
2010
7 048
9 154
7 867
573
9 607
4 580
1 216
4 430
45 684
55 608
8 322
9 984
2 829
50 200
2 121
2 779
314
327
11 487
29 561
8 858
18 407
4 068
1 580
30 455
7 485
52 350
7 467
9 656
8 490
615
9 856
4 929
1 361
4 606
50 772
61 098
8 793
10 338
2 957
53 822
2 359
3 140
339
303
13 039
32 526
8 680
20 250
4 538
1 670
33 815
8 043
55 663
7 549
9 859
8 862
509
10 303
5 123
1 477
4 780
53 880
61 549
9 643
10 711
3 411
56 434
2 512
3 413
364
317
14 150
35 578
9 766
22 207
4 980
1 832
37 439
8 311
56 314
7 678
9 967
8 718
580
10 333
5 141
1 569
4 986
56 709
62 679 |
10 157
10 374
3 514
56 719
2 663
3 698
382
354
14 952
38 111
9 983
23 202
5 299
1 998
38 850
8 559
57 248
8 012
10 251
8 170
694
10 272
5 340
1 369
5 176
59 062
82 212
10 918
10 211
3 804
56 942
2 373
3 500
436
386
15 926
38 454
10 226
22 443
5 389
1 989
40 263
8 872
58 893
8 390
10 896
7 534
804
10 520
5 548
1 340
5 363
62 959
81 777
11 308
10 000
4 475
60 483
2 239
3 287
507
416
16 615
38 184
10 637
21 438
5 430
2 049
46 071
9 378
62 231
386 892
419 123
441 271
454 423
481 581
499 879
4 140
1 392
176
..
3 581
..
5 328
27 438
4 412
1 629
204
..
3 876
..
6 181
35 294
4 600
1 891
228
..
4 086
..
6 319
44 522
4 777
1 882
255
..
4 242
..
6 712
56 104
4 468
2 026
281
614
4 491
7 516
7 184
67 393
4 419
2 055
318
617
4 889
7 291
7 822
73 142
| Break in series.
1. Population figures for Germany prior to 1991 refer to West Germany.
1 2 http://dx.doi.org/10.1787/888932705710
143
ANNEX A
Table A.2. Share of the population aged 65 and over, mid-year, 1960 to 2010
1960
1970
1980
1990
2000
2010
Austria
12.2
14.1
15.4
14.9
15.4
17.6
Belgium
12.0
13.4
14.3
14.9
16.8
17.2
Bulgaria
7.5
9.6
11.9
13.2
16.3
17.6
Cyprus1
..
..
10.8
10.9
11.3
13.0
9.5
12.0
13.4
12.5
13.8
15.4
Denmark
10.6
12.3
14.4
15.6
14.8
16.6
Estonia
10.5
11.7
12.5
11.6
15.1
17.0
Finland
7.3
9.2
12.0
13.4
14.9
17.3
France
11.6
12.9
13.9
14.0
16.1
16.9
Germany2
10.8
13.1
15.5
15.5 |
16.4
20.6
Greece
8.2
11.1
13.1
13.7
16.6
19.1
Hungary
9.0
11.6
13.4
13.3
15.1
16.7
11.1
11.1
10.7
11.4
11.2
11.5
9.3
10.9
13.1
14.9
18.3
20.3
Latvia
..
12.0
12.9
11.8
15.0
17.4
Lithuania
..
10.0
11.2
10.9
13.9
16.3
10.9
12.5
13.6
13.4
14.1
13.9
..
..
8.3
10.4
12.2
15.2
Netherlands
9.0
10.2
11.5
12.8
13.6
15.4
Poland
5.8
8.2
10.1
10.1
12.2
13.5
Portugal
7.9
9.4
11.3
13.4
16.2
18.0
Romania
..
8.6
10.3
10.4
13.3
14.9
Slovak Republic
6.9
9.1
10.5
10.3
11.4
12.3
Slovenia
7.8
9.9
11.4
10.7
14.0
16.5
Spain
8.2
9.6
11.0
13.6
16.8
17.0
Sweden
11.8
13.7
16.3
17.8
17.3
18.3
United Kingdom
11.7
13.0
14.9
15.7
15.8
16.5
..
..
12.5
13.0
14.7
16.4
..
..
..
..
16.0
17.1
..
..
..
..
10.0
11.7
8.1
8.8
9.9
10.6
11.6
12.1
..
..
..
..
11.9
12.7
11.0
12.9
14.8
16.3
15.2
15.0
..
..
..
..
16.1
16.9
10.2
11.4
13.8
14.6
15.3
17.5
3.6
4.4
4.7
4.4
5.4
7.1
Czech Republic
Ireland
Italy
Luxembourg
Malta
EU
Croatia
3
FYR of Macedonia
Iceland
Montenegro4
Norway
Serbia
Switzerland
Turkey
| Break in series.
1. Data for Cyprus in 1980 refers to 1982.
3. Data for Croatia in 2000 refers to 2002.
4. Data for Montenegro in 2000 refers to 2003.
1 2 http://dx.doi.org/10.1787/888932705729
144
ANNEX A
Table A.3. Crude birth rate, per 1 000 population, 1960 to 2010
1960
1970
1980
1990
Austria
17.9
15.0
12.0
11.8
9.8
9.4
Belgium
16.8
14.7
12.6
12.4
11.4
11.9
Bulgaria
17.8
16.3
14.5
12.1
9.0
10.0
Cyprus1
26.2
19.2
20.4
18.3
12.2
11.8
Czech Republic
13.4
15.0
14.9
12.6
8.8
11.1
Denmark
16.6
14.4
11.2
12.3
12.6
11.4
Estonia
16.6
15.8
15.0
14.2
9.5
11.8
Finland
18.5
14.0
13.2
13.1
11.0
11.4
France
17.9
16.7
14.9
13.4
13.1
12.7
Germany2
17.4
13.3
10.1
11.5 |
9.3
8.3
Greece
18.9
16.5
15.4
10.1
9.5
10.1
Hungary
14.7
14.7
13.9
12.1
9.6
9.0
Ireland
21.5
21.8
21.7
15.1
14.4
16.5
Italy
18.1
16.7
11.3
10.0
9.5
9.3
Latvia
16.7
14.6
14.1
14.2
8.5
8.6
Lithuania
22.5
17.7
15.2
15.4
9.8
10.8
Luxembourg
16.0
13.0
11.4
12.9
13.1
11.6
Malta
26.2
17.6
17.7
15.2
11.5
9.6
Netherlands
20.8
18.3
12.8
13.2
13.0
11.1
Poland
22.6
16.8
19.6
14.4
9.8
10.8
Portugal
24.1
20.8
16.2
11.7
11.7
9.5
Romania
19.1
21.1
17.9
13.6
10.4
9.9
Slovak Republic
21.7
17.8
19.1
15.1
10.2
11.1
Slovenia
17.6
15.9
15.7
11.2
9.1
10.9
Spain
21.7
19.5
15.3
10.3
9.9
10.5
Sweden
13.7
13.7
11.7
14.5
10.2
12.3
United Kingdom
17.5
16.2
13.4
13.9
11.5
13.0
EU
19.0
16.6
14.9
13.1
10.7
10.9
Croatia
18.4
13.8
14.8
11.6
9.8
9.8
FYR of Macedonia
31.7
23.2
21.0
18.8
14.5
11.8
Iceland
28.0
19.7
19.8
18.7
15.3
15.4
..
..
..
..
15.0
12.0
17.3
16.7
12.5
14.4
13.2
12.6
..
..
..
..
9.8
9.4
17.7
16.1
11.7
12.5
10.9
10.3
..
..
..
..
20.2
16.9
Montenegro
Norway
Serbia
Switzerland
Turkey
2000
2010
| Break in series.
1. Data for Cyprus in 1960 refers to 1961.
1 2 http://dx.doi.org/10.1787/888932705748
145
ANNEX A
Table A.4. Fertility rate, number of children per women aged 15-49, 1960 to 2010
1960
1970
1980
1990
2000
2010
Austria
2.7
2.3
1.7
1.5
1.4
1.4
Belgium
2.5
2.3
1.7
1.6
1.7
1.9
Bulgaria
2.3
2.2
2.1
1.8
1.3
1.5
Cyprus1
..
..
2.5
2.4
1.6
1.5
Czech Republic
2.1
1.9
2.1
1.9
1.1
1.5
Denmark
2.5
2.0
1.5
1.7
1.8
1.9
Estonia
..
..
2.0
2.0
1.4
1.6
Finland
2.7
1.8
1.6
1.8
1.7
1.9
France
2.7
2.5
1.9
1.8
1.9
2.0
Germany
2.4
2.0
1.6
1.5
1.4
1.4
Greece
2.2
2.4
2.2
1.4
1.3
1.5
Hungary
2.0
2.0
1.9
1.8
1.3
1.3
Ireland
3.8
3.9
3.2
2.1
1.9
2.1
Italy
2.4
2.4
1.7
1.4
1.3
1.4
Latvia2
..
..
..
..
1.2
1.2
Lithuania
..
2.4
2.0
2.0
1.4
1.6
2.3
2.0
1.5
1.6
1.8
1.6
..
..
2.0
2.0
1.7
1.4
Netherlands
3.1
2.6
1.6
1.6
1.7
1.8
Poland
3.0
2.2
2.3
2.0
1.4
1.4
Portugal
3.1
2.8
2.2
1.6
1.6
1.4
Romania3
..
..
2.4
1.8
1.3
1.4
Slovak Republic
3.1
2.4
2.3
2.1
1.3
1.4
Slovenia
2.2
2.2
2.1
1.5
1.3
1.6
Spain
2.9
2.9
2.2
1.4
1.2
1.4
Sweden
2.2
1.9
1.7
2.1
1.5
2.0
United Kingdom
2.7
2.4
1.9
1.8
1.6
2.0
..
..
2.0
1.8
1.5
1.6
..
..
..
..
1.3
1.5
..
..
..
..
1.9
1.6
4.3
2.8
2.5
2.3
2.1
2.2
..
..
..
..
..
1.7
Norway
2.9
2.5
1.7
1.9
1.9
2.0
Serbia
..
..
..
..
1.5
1.4
Switzerland
2.4
2.1
1.6
1.6
1.5
1.5
Turkey
6.4
5.0
4.6
3.1
2.3
2.0
Luxembourg
Malta
EU
Croatia
2
FYR of Macedonia
Iceland
Montenegro
1. Data for Cyprus in 1980 and 2010 refer to 1982 and 2009 respectively.
2. Data for Latvia and Croatia in 2000 refer to 2002.
3. Data for Romania in 2010 refers to 2009.
1 2 http://dx.doi.org/10.1787/888932705767
146
ANNEX A
Table A.5. GDP per capita in 2010 and average annual growth rates, 1980 to 2010
GDP per capita in EUR PPP
Annual growth rate in real terms
2010
1980-90
1990-2000
2000-10
Austria
30 793
2.0
2.2
1.1
Belgium
28 943
1.9
1.9
0.8
Bulgaria
10 678
..
..
4.9
Cyprus
24 223
..
..
1.3
Czech Republic
19 431
..
0.5
3.1
Denmark
30 941
2.0
2.2
0.2
Estonia3
15 678
..
6.5
3.7
Finland
28 095
2.6
1.7
1.4
France
26 268
1.9
1.5
0.5
Germany2, 4
28 769
2.1
1.3
1.0
Greece
21 898
0.2
1.6
1.8
Hungary4
15 806
..
1.9
2.2
Ireland
31 147
3.3
6.0
0.7
Italy
24 561
2.4
1.6
-0.2
Latvia
12 469
..
..
4.3
Lithuania
13 848
..
..
4.9
Luxembourg
66 207
4.5
3.6
1.2
Malta
20 293
..
..
0.7
Netherlands
32 442
1.7
2.5
0.9
Poland
15 286
..
3.7
4.0
Portugal
19 549
3.0
2.7
0.2
Romania
11 353
..
..
4.6
Slovak Republic5
17 914
..
3.7
4.7
Slovenia
20 728
..
1.9
2.4
Spain
24 477
2.6
2.4
0.7
Sweden
30 287
1.9
1.7
1.5
United Kingdom
27 400
2.6
2.6
1.1
EU27 (unweighted)
24 055
..
..
2.0
EU27 (weighted)1
24 474
..
..
1.0
Croatia
14 505
..
..
2.7
8 872
..
..
2.4
Iceland
27 188
1.6
1.5
0.9
Montenegro
10 142
..
..
4.5
Norway
44 149
2.1
3.1
0.6
Serbia6
8 405
..
..
4.7
Switzerland
35 718
1.6
0.4
0.8
Turkey
11 970
2.8
1.8
3.0
FYR of Macedonia
1. The weighted average is calculated based on total GDP divided by the total population of the 27 EU member states.
2. Data prior to 1990 refers to Western Germany.
3. Data available from 1993.
6. Latest year 2009.
1 2 http://dx.doi.org/10.1787/888932705786
147
ANNEX A
Table A.6. Total expenditure on health per capita in 2010,
average annual growth rates, 2000 to 2010
Total health expenditure
per capita in EUR PPP
Annual growth rate per capita in real terms1
2010
2006/07
2007/08
2008/09
2009/10
2000-10
(or latest year)
Austria
3 383
3.7
3.2
2.3
0.1
2.0
Belgium9
3 052
2.5
4.2
2.8
0.2
3.4
Bulgaria5
745
5.8
9.3
-1.7
..
4.1
Cyprus7
1 783
-0.3
16.4
4.4
-0.2
2.2
Czech Republic
1 450
2.4
6.8
11.1
-4.4
4.9
Denmark
3 439
1.8
0.6
5.3
-2.1
2.7
Estonia
995
10.7
12.7
-0.5
-7.3
5.6
Finland
2 504
1.1
3.1
0.7
0.4
3.6
France
3 058
1.5
-1.4
2.7
0.8
1.9
Germany
3 337
1.8
3.4
4.3
2.7
2.1
Greece
2 244
3.6
2.6
0.5
-6.7
4.4
Hungary
1 231
-6.8
-1.7
-3.2
2.2
3.0
Ireland
2 862
5.6
9.6
2.7
-7.9
5.0
Italy
2 282
-2.8
1.0
-1.6
1.0
1.3
Latvia6
821
13.6
-8.1
-14.8
..
2.7
Lithuania8
972
10.8
9.7
-2.2
-5.0
6.4
Luxembourg3
3 607
-4.9
-7.1
7.5
..
0.6
Malta
1 758
-3.3
-0.2
-0.8
3.6
3.5
Netherlands
3 890
..
3.2
3.6
2.0
5.2
Poland
1 068
9.1
14.3
6.4
0.5
6.4
Portugal
2 097
1.7
2.1
2.7
0.5
1.7
677
9.6
11.5
-3.0
4.2
5.4
Slovak Republic
1 614
16.5
9.2
8.2
2.4
10.0
Slovenia
1 869
1.0
9.2
1.9
-2.0
3.3
Spain
2 345
2.8
4.6
2.8
-0.9
3.6
Sweden
2 894
2.2
2.1
1.4
1.2
3.1
United Kingdom
2 636
3.0
1.5
6.3
-0.5
4.3
EU27 (unweighted)
2 171
3.6
4.5
1.9
-0.6
3.8
EU27 (weighted)2
2 470
1.7
2.3
3.4
0.4
2.8
Croatia
1 152
12.7
5.2
-5.9
-1.2
2.7
619
-7.2
3.9
-0.6
5.7
0.1
2 524
3.2
-0.9
-1.4
-7.1
0.7
899
0.4
8.1
11.7
..
5.9
Norway
4 156
2.7
2.6
1.6
-2.0
2.4
Serbia3
902
18.1
6.0
-1.3
..
8.9
4 056
1.2
2.0
2.9
1.4
1.9
714
10.2
0.0
..
..
6.4
Romania7
FYR of Macedonia
Iceland
Montenegro3
Switzerland
Turkey4
1. Using national currency units at 2005 GDP price level.
2. The weighted average is calculated based on total health spending divided by the total population of the 27 EU
member states.
3. Most recent year 2009.
4. Most recent year 2008.
5. Data for 2003-09.
6. Data for 2004-09.
7. Data since 2003.
8. Data since 2004.
9. Excluding investment.
1 2 http://dx.doi.org/10.1787/888932705805
148
ANNEX A
Table A.7. Total expenditure on health, percentage of GDP, 1980 to 2010
1980
1990
2000
2005
2007
2008
2009
2010
Austria
7.4 |
8.4
10.0
10.4
10.3
10.5
11.2 |
11.0
Belgium2
6.3
7.2
8.1
10.1
9.6
10.0
10.7
10.5
Bulgaria
..
..
6.2
7.3
6.8
7.0
7.2
..
Cyprus
..
..
5.8
6.4
6.1
6.9
7.4
7.4
..
4.5 |
6.3 |
6.9
6.5
6.8
8.0
7.5
8.9
8.3
8.7 |
9.8
10.0
10.2
11.5
11.1
Czech Republic
Denmark
Estonia
..
..
5.3
5.0
5.2
6.0
7.0 |
Finland
6.3
7.7 |
7.2
8.4
8.0
8.3
9.2
8.9
France
7.0
8.4 |
10.1
11.2
11.1
11.0
11.7
11.6
Germany
8.4
8.3 |
10.4
10.8
10.5
10.7
11.7
11.6
Greece
5.9
6.7
8.0
9.7
9.8
10.1
10.6
10.2
..
7.1
7.2
8.4
7.7
7.5
7.7
7.8
8.2
6.0
6.1
7.6
7.8
8.9
9.9
9.2
Italy
..
7.7
8.0
8.9
8.6 |
8.9
9.3
9.3
Latvia
..
..
6.0
6.4
7.0
6.6
6.8
..
Lithuania
..
..
6.5
5.8
6.2
6.6
7.5
7.0
5.2
5.4 |
7.5
7.9
7.1
6.8
7.9
..
..
..
6.7
9.3
8.7
8.3
8.5
8.6
7.4
8.0 |
8.0
9.8 |
10.8
11.0
11.9
12.0
..
4.8
5.5 |
6.2
6.3
6.9
Portugal
5.1
5.7 |
9.3
10.4
10.0
10.2
10.8
10.7
Romania
..
..
5.2
5.5
5.2
5.4
5.6
6.0
Slovak Republic
..
..
5.5
7.0
7.8
8.0
9.2
9.0
Slovenia
..
..
8.3 |
8.3
7.8
8.3
9.3
9.0
Spain
5.3
6.5 |
7.2 |
8.3
8.5
8.9
9.6
9.6
Sweden
8.9
8.2 |
8.2
9.1
8.9
9.2
9.9
9.6
United Kingdom
5.6
5.9 |
7.0
8.2
8.5
8.8
9.8
9.6
..
..
7.3
8.3
8.2
8.4
9.2
9.04
..
..
8.6
9.5
9.4
9.6
10.4
10.3
Croatia
..
..
7.8
7.0
7.5
7.8
7.8
7.8
FYR of Macedonia
..
..
8.8
8.1
6.9
6.8
6.9
7.1
6.3
7.8
9.5
9.4
9.1
9.1
9.6
9.3
..
..
7.9
9.1
7.8
8.0
9.4
9.1
Norway
7.0
7.6 |
8.4 |
9.0
8.7
8.6
9.8
9.4
Serbia
..
..
7.4
9.1
10.4
10.4
10.5
10.4
Switzerland
7.4
8.2 |
10.2
11.2
10.6
10.7
11.4
11.4
Turkey
2.4
2.7 |
4.9
5.4
6.0
6.1
..
..
Hungary3
Ireland
Luxembourg
Malta
Netherlands
Poland
EU27 (unweighted)
EU27
(weighted)1
Iceland
Montenegro
7.2 |
6.3
7.0
| Break in series.
1. The weighted average is calculated based on total health spending divided by total GDP across the 27 EU member
states.
2. Excluding investment.
3. Data for 1990 refers to 1991.
4. The average is calculated on the most recent data available.
1 2 http://dx.doi.org/10.1787/888932705824
149
ORGANISATION FOR ECONOMIC CO-OPERATION
AND DEVELOPMENT
The OECD is a unique forum where governments work together to address the economic, social and
environmental challenges of globalisation. The OECD is also at the forefront of efforts to understand and
to help governments respond to new developments and concerns, such as corporate governance, the
information economy and the challenges of an ageing population. The Organisation provides a setting
where governments can compare policy experiences, seek answers to common problems, identify good
practice and work to co-ordinate domestic and international policies.
The OECD member countries are: Australia, Austria, Belgium, Canada, Chile, the Czech Republic,
Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Korea,
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(81 2012 12 1 P) ISBN 978-92-64-18360-5 – No. 60319 2012
Health at a Glance
Europe 2012
This second edition of Health at a Glance: Europe presents a set of key indicators of health status,
determinants of health, health care resources and activities, quality of care, health expenditure and financing
in 35 European countries, including the 27 European Union member states, 5 candidate countries and 3 EFTA
countries. The selection of indicators is based largely on the European Community Health Indicators (ECHI)
shortlist, a set of indicators that has been developed to guide the reporting of health statistics in the European
Union. It is complemented by additional indicators on health expenditure and quality of care, building on
the OECD expertise in these areas. Each indicator is presented in a user-friendly format, consisting of charts
illustrating variations across countries and over time, a brief descriptive analysis highlighting the major findings
conveyed by the data, and a methodological box on the definition of the indicator and any limitations in data
comparability.
Contents
Chapter 1. Health status
Chapter 2. Determinants of health
Chapter 3. Health care resources and activities
Chapter 4. Quality of care
Chapter 5. Health expenditure and financing
Please cite this publication as:
OECD (2012), Health at a Glance: Europe 2012, OECD Publishing.
http://dx.doi.org/10.1787/9789264183896-en
This work is published on the OECD iLibrary, which gathers all OECD books, periodicals and statistical databases.
Visit www.oecd-ilibrary.org, and do not hesitate to contact us for more information.
isbn 978-92-64-18360-5
81 2012 12 1 P
-:HSTCQE=V]X[UZ:
CONTENIDO: 1
Panorama de la salud: Europa 2012 2
Se prohíbe la reproducción total o parcial del contenido de este "Boletín Europa al Día " sin citar la fuente
o sin haber obtenido el permiso del Consejo General de Colegios Médicos de España.
2
Disponible en la página web del Consejo General de Colegios Médicos: http://www.cgcom.es
1
Panorama de la salud: Europa 2012
La Comisión Europea y la OCDE han publicado conjuntamente un informe que
recoge los indicadores clave sobre los factores determinantes de la salud, los
recursos y actividades de la asistencia sanitaria, la calidad de la atención sanitaria
y el gasto y la financiación de la salud en 35 países europeos
En general, la situación sanitaria ha mejorado considerablemente aunque siguen
existiendo grandes diferencias. El número de médicos y de enfermeros per cápita
es más alto que nunca en la mayoría de los países, pero preocupa la escasez actual
o futura de personal.
La DG Salud y Consumidores de la Comisión Europea y la Organización de Cooperación y
Desarrollo Económicos (OCDE) han publicado conjuntamente la segunda edición del
informe "Panorama de la salud: Europa 2012".
Este informe presenta una serie de indicadores clave sobre los factores determinantes de
la salud, los recursos y actividades de la asistencia sanitaria, la calidad de la atención
sanitaria y el gasto y la financiación de la salud en 35 países europeos, que son, los 27
Estados miembros de la UE, 5 países candidatos y 3 países de la AELC/EFTA.
Hasta el año 2009, el gasto sanitario en Europa creció más deprisa que el resto de la
economía, y el sector de la salud absorbió una creciente proporción del Producto Interior
Bruto (PIB). Debido al estallido de la crisis económica y financiera en 2008, muchos países
europeos redujeron el gasto en asistencia sanitaria como parte de un esfuerzo más amplio
para controlar los graves déficits presupuestarios y los crecientes ratios deuda/PIB. Aunque
esos recortes fueran posiblemente inevitables, algunas medidas pueden haber afectado los
objetivos fundamentales de los sistemas sanitarios.
Panorama de la salud: Europa 2012 presenta las tendencias a lo largo del tiempo y las
variaciones en cuanto a cinco grandes temas:
1) estado de salud de la población;
2) factores de riesgo para la salud;
3) recursos y actividades de los sistemas de atención sanitaria;
4) calidad de la atención en caso de enfermedades crónicas y dolencias agudas;
5) gasto sanitario y fuentes de financiación.
2
Mejoras en la calidad de la atención sanitaria:
• Se han registrado progresos en el tratamiento de las afecciones potencialmente mortales
como el ataque al corazón, o el ictus y el cáncer, en todos los países europeos incluidos en
el estudio. Los índices de mortalidad tras una hospitalización por un ataque al corazón
(infarto agudo de miocardio) disminuyeron casi en un 50 % entre 2000 y 2009. y en más del
20 % en el caso del ictus. Estas mejoras se reflejan en la atención de las dolencias agudas y
en un mayor acceso a las unidades exclusivamente destinadas al ictus en países como
Dinamarca y Suecia.
• También han mejorado los índices de supervivencia para distintos tipos de cáncer en casi
todos los países, gracias a una detección precoz y a una mejor eficacia de los tratamientos.
Los índices de supervivencia en el caso del cáncer de mama siguen siendo inferiores al 80 %
en Chequia y Eslovenia, pero aumentaron en más de diez puntos porcentuales entre 19972002 y 2004-2009. Estos dos países también han experimentado una notable mejoría en
sus índices de supervivencia relativos al cáncer colorrectal.
Gasto sanitario:
• El aumento del gasto sanitario per cápita se ralentizó o incluso se detuvo en términos
reales en 2010 en casi todos los países europeos, lo que invirtió una tendencia de
incremento constante. El gasto ya había comenzado a reducirse en 2009 en los países que
se habían visto más afectados por la crisis económica (por ej. Estonia e Islandia), pero a
continuación, en 2010 se produjeron recortes más profundos en respuesta a las sucesivas
presiones presupuestarias y a los crecientes ratios deuda/PIB. En la UE, el gasto sanitario
per cápita aumentó como término medio en un 4,6 % anual en términos reales entre 2000
y 2009, y descendió a continuación un 0,6 % en 2010.
3
Recortes del gasto público en el ámbito sanitario:
• Los recortes del gasto público en el ámbito sanitario se llevaron a cabo a través de una
serie de medidas, que incluyen reducciones de salarios y/o de nivel de empleo, lo cual
provoca un aumento de los pagos directos de los hogares para determinados servicios y
productos farmacéuticos e impone rigurosas restricciones presupuestarias a los hospitales.
También se han llevado a cabo fusiones de hospitales y acelerado la transición de la
hospitalización a la asistencia y la cirugía ambulatorias.
• Como consecuencia del crecimiento negativo del gasto sanitario en 2010, el porcentaje
del PIB destinado a asistencia sanitaria se estabilizó o disminuyó ligeramente en
numerosos Estados miembros de la UE, que en 2010, destinaron una media del 9,0 % (no
ponderada) de su PIB a la asistencia sanitaria, lo que significa una importante subida en
relación con el 7,3 % de 2000, pero es ligeramente inferior al máximo del 9,2 % alcanzado
en 2009.
• Holanda fue el país que destinó el mayor porcentaje del PIB a sanidad en 2010 (12%),
seguido de Francia y Alemania (ambas el 11,6%). En términos de gasto en asistencia
sanitaria per cápita, los Países Bajos (3.890 EUR), Luxemburgo (3.607 EUR) y Dinamarca
(3.439 EUR) fueron los Estados miembros de la UE que más gastaron. Les siguen Austria,
Francia y Alemania, con más de 3.000 EUR per cápita. Bulgaria y Rumanía fueron los países
que menos gastaron, en torno a 700 EUR.
• El sector público es la principal fuente de financiación de la asistencia sanitaria en todos
los países europeos excepto en Chipre. En 2010, casi tres cuartas partes (73%) de todo el
gasto en sanidad, como media, se financiaron con fondos públicos en los Estados
miembros de la UE. En los Países Bajos, los países nórdicos (excepto Finlandia),
Luxemburgo, Chequia, el Reino Unido y Rumanía, más del 80% del gasto se financió con
fondos públicos. El porcentaje más bajo se registró en Chipre (43%) y en Bulgaria, Grecia y
Letonia (55-60%).
• En algunos países, la crisis económica ha afectado al equilibrio entre la financiación
pública y privada de la asistencia sanitaria. Se ha recortado el gasto público en
4
determinados bienes y servicios, a veces en combinación con aumentos en el porcentaje
de los pagos directos para los hogares. En Irlanda, el porcentaje de la financiación pública
del gasto sanitario disminuyó en casi seis puntos porcentuales entre 2008 y 2010, y se sitúa
actualmente en el 70%, mientras que aumentó el porcentaje de los pagos directos
realizados por los hogares. También ha habido descensos significativos en Bulgaria y
Eslovaquia.
• Tras la financiación pública, la fuente principal de financiación del gasto sanitario en la
mayoría de los países son los pagos directos. La financiación mediante un seguro médico
privado solo juega un papel importante en unos pocos países. En 2010, el porcentaje de
pagos directos más elevado se dio en Chipre (49%), Bulgaria (43%) y Grecia (38%). El más
bajo lo registraron los Países Bajos (6%), Francia (7%) y el Reino Unido (9%). Este
porcentaje aumentó durante la última década en casi la mitad de los Estados miembros de
la UE, sobre todo en Bulgaria, Chipre, Malta y Eslovaquia.
Número de médicos:
• Garantizar un acceso adecuado a la asistencia sanitaria es un objetivo político
fundamental en todos los Estados miembros de la UE que requiere, entre otras cosas,
disponer del número adecuado de profesionales de la salud distribuido de manera que
responda a las necesidades de la población. En muchos países europeos preocupa la falta
de médicos y de enfermeros, a pesar de que los recientes recortes del gasto público en el
ámbito sanitario en algunos países puedan haber dado lugar a una reducción al menos
temporal de la demanda. Desde 2000, el número de médicos per cápita ha aumentado en
casi todos los Estados miembros de la UE que, como término medio, pasó de 2,9 médicos
por mil habitantes en 2000 a 3,4 en 2010. El aumento fue especialmente rápido en Grecia y
el Reino Unido.
5
Médicos generalistas y especialistas:
• En casi todos los países, el equilibrio entre médicos generalistas y especialistas ha
cambiado, de manera que ahora hay más especialistas. La explicación puede ser un menor
interés por la práctica de la «medicina de cabecera» tradicional, junto con una creciente
diferencia salarial entre generalistas y especialistas. El crecimiento lento o la reducción del
número de médicos generalistas afecta en muchos países a la atención primaria para
determinados grupos de población.
Enfermedades crónicas:
• Se observa un aumento de enfermedades crónicas, como la diabetes, el asma y la
demencia, debido a un mejor diagnóstico o a que esas dolencias están aumentando
realmente. Más de un 6% de personas de edades comprendidas entre 20 y 79 años en la
Unión Europea, lo que equivale a 30 millones de personas, tenían diabetes en 2011.
Gestionar mejor las enfermedades crónicas se ha convertido en una prioridad de política
sanitaria para numerosos Estados miembros de la UE.
6
Tabaquismo:
• La mayor parte de los países europeos han reducido el consumo de tabaco mediante
campañas de sensibilización de la opinión pública, la prohibición de la publicidad y mayores
impuestos. El porcentaje de adultos que fuman a diario está por debajo del 15% en Suecia
e Islandia, frente al 30% registrado en 1980. En el otro extremo, más de un 30% de adultos
fuman diariamente en Grecia. El índice de tabaquismo sigue siendo elevado en Bulgaria,
Irlanda y Letonia.
2.5.1. Población activa que fuma diariamente y cambios en la tasa de fumadores de 2000-2010
Alcohol:
• Ha descendido el consumo de alcohol en muchos países europeos. Se ha demostrado que
las restricciones de la publicidad y venta y el aumento de los impuestos son medidas
eficaces. En países vitícolas tradicionales, como España, Francia e Italia, el consumo per
cápita ha descendido mucho desde 1980. El consumo de alcohol por adulto aumentó
considerablemente en Chipre, Finlandia e Irlanda.
7
2.6.1. Consumo de alcohol entre la población de 15 y más años y cambios 1980-2010.
Sobrepeso:
• En la Unión Europea, el 52% de la población adulta tiene sobrepeso, el 17% de la cual es
obesa. A nivel nacional, la frecuencia del sobrepeso y la obesidad supera el 50% en
dieciocho de los veintisiete Estados miembros de la UE. Los índices son mucho más bajos
en Francia, Italia y Suiza, aunque también están subiendo en estos países. La frecuencia de
la obesidad, que supone un riesgo mayor para la salud que el sobrepeso, va de menos de
un 8% en Rumanía y Suiza a más de un 25% en Hungría y el Reino Unido. El índice de
obesidad se ha duplicado desde 1990 en muchos países europeos. El aumento de la
obesidad ha afectado a todos los grupos de población, en distintos grados, aunque tiende a
ser más común entre los grupos sociales desfavorecidos y especialmente entre las mujeres.
2.7.2. Aumento de la obesidad entre los adultos Europeos, 1990, 2000, 2010
8
Esperanza de vida:
• La esperanza de vida al nacer en los Estados miembros de la UE aumentó en seis años
desde 1980 y 2010. Francia tiene la esperanza de vida más alta para las mujeres (85 años) y
Suecia para los hombres (79,4 años). Bulgaria y Rumanía tienen la esperanza de vida al
nacer más baja de la UE para las mujeres (77,3 años) y Lituania para los hombres (67,3
años). La diferencia entre Estados miembros de la UE con las esperanzas de vida al nacer
más altas y bajas se encuentra en torno a ocho años para las mujeres y doce para los
hombres.
Personal de enfermería:
• También preocupa la posible escasez de personal de enfermería, lo cual puede
intensificarse en el futuro ya que la demanda de enfermeros sigue aumentando y el
envejecimiento de la generación del baby boom provoca una oleada de jubilaciones en esa
profesión. En la última década, el número de enfermeros per cápita aumentó en casi todos
los Estados miembros de la UE. El aumento fue especialmente elevado en Dinamarca,
Francia, Portugal y España. Sin embargo, recientemente ha habido una reducción de los
enfermeros contratados en determinados países que se han visto más afectados por la
crisis económica. En Estonia, el número de enfermeros aumentó hasta 2008, pero después
disminuyó, pasando de 6,4 por mil habitantes en 2008 a 6,1 en 2010.
Entre las principales conclusiones del informe, pueden señalarse las siguientes:
•
La esperanza de vida al nacer en los países de la UE aumentó en más de seis años
entre 1980 y 2010.
•
La prevalencia de enfermedades crónicas como la diabetes, el asma y la demencia
es cada vez más elevada.
•
La mayor parte de los países europeos ha reducido el consumo de tabaco mediante
campañas de sensibilización de la opinión pública, la prohibición de la publicidad y
mayores impuestos.
•
El aumento del gasto sanitario per cápita se ralentizó o incluso se detuvo en
términos reales en 2010 en casi todos los países europeos, lo que invirtió una
tendencia de incremento constante.
Incluimos, en el presente Boletín “Europa al día” el informe “panorama de la salud: Europa
2012”, del que sólo existe versión inglesa.
**********
9
CONCLUSIONES VIH 2012 (DOCUMENTO DE CONCLUISIONES: ESPAÑA
VIH 2012. PLATAFORMA VIH EN ESPAÑA)
______________________________________________________________________
Las tasas de nuevos diagnósticos de VIH en España son similares a las de otros
países en Europa Occidental, aunque superiores a la media del conjunto de la
Unión Europea.
El retraso en el diagnóstico es una asignatura pendiente y solo ha descendido entre
los HSH. Por lo tanto, promover el diagnóstico precoz debe ser un factor clave
para el control de la epidemia en Europa. Aún en un entorno de crisis económica,
se deben potenciar los programas de prevención y diagnóstico precoz del VIH.
Además, los últimos estudios de evaluación económica señalan el coste-eficacia de
un diagnóstico precoz. Un punto clave a la hora de hablar del tratamiento es evaluar el
beneficio coste-eficacia y conocer cual es la mejor manera de optimizar los recursos
cuando estos son limitados. Según los datos presentados en la conferencia, la terapia
antirretroviral es coste-efectiva y desde el año 1999 a 2004 su coste se ha reducido a
menos de la mitad.
En función de las características de la epidemia en cada país y de su sistema sanitario,
se deben desarrollar estrategias concretas de promoción del diagnóstico precoz.
Cada vez más, las ONGs están desarrollando una importante labor en materia de
prevención, formación y diagnóstico precoz del VIH pro su capacidad de acercarse a la
población joven, un segmento de la población de difícil acceso para el sistema sanitario.
Impacto positivo del diagnóstico precoz
Actualmente existe consenso sobre el impacto positivo del diagnóstico precoz y
cómo el tratamiento de las personas diagnosticadas supone una medida relevante
para la prevención de nuevas infecciones, mientras que el infradiagnóstico tiene
implicaciones negativas para la propagación de la epidemia y la evolución clínica de los
propios afectados.
En el encuentro celebrado en Madrid, los expertos han debatido sobre las medidas más
adecuadas para llevar a cabo esta detección temprana que en España deberían
enmarcarse dentro de la Ley de Salud Pública, aprobada en septiembre de 2011. En este
sentido, e independientemente del método que se adopte, se considera indispensable la
implicación de los gobiernos locales, nacionales y de las instituciones sanitarias
europeas.
El diagnóstico precoz pasa necesariamente por aumentar el número de pruebas que se
realizan actualmente, con un cambio en los criterios que hoy se aplican para solicitarlas.
Este es uno de los puntos clave donde las administraciones deben intervenir para
facilitar la labor de los profesionales.
El acceso a la prueba y al tratamiento temprano, por tanto, es fundamental para la
prevención, ya que sin diagnóstico no hay acceso al tratamiento y la transmisión de
la infección es mayor. Así, la importancia de realizar el diagnóstico a tiempo reside en
que cuanto más tarda en detectarse la infección, mayor es la morbilidad y la mortalidad.
Por otra parte, tal y como señaló el Dr. Moreno en la clausura del encuentro, “no es
cuestión de voluntarismo”, sino de adoptar “medidas a gran escala en las que estén
implicadas las Administraciones sanitarias”.
Infección por VIH
Como resultado de los datos y opiniones expuestos durante la Reunión VIH 2012, los
expertos destacan que en Europa existen entre 700.000-900.000 personas que están
infectadas con el VIH y que aún no se han diagnosticado, lo que da lugar, por un lado,
al inicio tardío del tratamiento, y por otro, a un incremento en el riesgo de transmisión a
otras personas.
El incremento de estos índices supone un problema desde la perspectiva de salud
pública, cuyo objetivo es aumentar el porcentaje de personas con VIH que saben
que están infectadas, sin olvidar que para conseguirlo el primer paso es disminuir
el número de personas que se infectan.
Desde el ámbito político y ejerciendo su papel de líderes a distintos niveles, también
deben tomarse medidas tanto a nivel local como nacional e internacional.
Comenzando por el Parlamento Europeo, donde se está intentando estandarizar medidas
que consigan el diagnóstico precoz de las enfermedades, gracias a la cooperación entre
las autoridades de los países miembros de la Unión y los países vecinos.
A nivel nacional, se intenta dar respuesta al problema del sida, promoviendo programas
de prevención, acceso al diagnóstico y tratamiento, brindando asesoramiento, y sin
olvidar la educación social.
Barreras que dificultan el acceso a la prueba del VIH por parte de la población
Entre las principales barreras que dificultan el acceso a la prueba se encuentran el
desconocimiento, la falta de percepción del riesgo por parte del paciente y de los
profesionales sanitarios y la posibilidad de que un positivo conlleve rechazo social.
Desde el punto de vista de los profesionales sanitarios, es imprescindible mejorar sus
habilidades clínicas sobre conductas de riesgo: prácticas sexuales y hábitos tóxicos. La
sensibilización, formación e información del personal sanitario es necesaria para
identificar marcadores clínicos y conductuales y promover el diagnóstico precoz, ya que
los datos indican que el 90 por ciento de los pacientes diagnosticados había acudido al
médico al menos una vez durante ese año. De hecho, la razón principal por la que los
infectados se realizaron la prueba del VIH fue la recomendación del médico de
Atención Primaria.
Otra de las barreras es el condicionante social, desde este punto de vista la
normalización de la enfermedad es todavía una asignatura pendiente.
Avances en el tratamiento del VIH
Los avances más significativos han sido el inicio de tratamiento antirretroviral en fases
más precoces de la infección – cuando el paciente se encuentra mejor – y la
incorporación a esquemas terapéuticos que proporcionan un tratamiento completo en un
solo comprimido al día. Por otra parte, el establecimiento de que el tratamiento es una
medida extraordinaria para prevenir la transmisión del VIH también ha modificado el
abordaje en muchos casos, por lo que se debe seguir facilitando el acceso al tratamiento,
aún en una situación de crisis económica y mejorar la adherencia. La adherencia
terapéutica es clave y se correlaciona con el éxito del tratamiento en todos los estudios.

Revista Quincenal Médicos de Soria - Colegio Oficial de Médicos de

Transcription

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