Health Glance 2014 en PDF

Health at a Glance:
Europe 2014
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FOREWORD
Foreword
s we emerge from the economic crisis, the squeeze on health budgets continues in many EU countries, and policy
makers face the challenge of maintaining universal access to essential and high-quality care with reduced resources.
The new chapter on Access to care in this edition of Health at a Glance Europe shows that the main
effort in this constrained budgetary environment has been to maintain universal coverage for a core set of health
services and goods. However, the coverage of other health services and goods has been reduced in several
countries and direct out-of-pocket payments by patients have increased. Policy makers are now facing challenges
in ensuring affordable health care for all. Moreover, the crisis, having huge social impact, has exacerbated the
unequal geographic distribution of health services and health professionals in many European countries. This
calls for policies to improve access to care, particularly for people living in rural and remote areas and in
deprived urban areas (for example by developing e-health tools).
The economic crisis has led to adverse population health outcomes. The number of people suffering from
depression has increased in several European countries, as a result of growing unemployment, financial
hardship and stress. Although broad measurements of health status such as life expectancy have continued to
improve in nearly all EU member states, it will take some additional years to be able to fully assess the impact
of the crisis on public health.
Despite the difficult financing conditions, the quality of care has continued to improve in recent years in
most European countries. For example, over the past decade mortality rates for people suffering from a heart
attack have decreased by 40%, and from strokes by 20%, on average across EU countries. However, large gaps
remain in the probability of surviving these life-threatening conditions across the European Union. Efforts are
needed to promote healthy lifestyle, protect healthy living standards and to improve the prevention, early
diagnosis and treatment of diseases in countries that are lagging behind. Countries across Europe need to ensure
that effective strategies are put in place to prevent diseases so as to reduce the disease burden and, as such, to
contribute to the sustainability of health systems.
This third edition of Health at a Glance Europe is the result of a long and fruitful collaboration between
the OECD and the European Commission in the development and reporting of key health statistics. The European
Core Health Indicators on public health and health systems presented in this publication are an important input
to public debates on policies to improve public health and health system performance across Europe. This report
underlines the need for reliable and sustainable data and information systems to support health policy
development in Europe.
Our hope is that this publication will help stimulate further actions so that European citizens of all socioeconomic background can enjoy longer, healthier and more active lives.
Angel Gurra
Secretary-General
Organisation for Economic Co-operation and Development
HEALTH AT A GLANCE: EUROPE 2014 OECD 2014
Vytenis Andriukaitis
European Commissioner for Health
and Food Safety
ACKNOWLEDGEMENTS
Acknowledgements
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
Gatan Lafortune. Chapter 1 was prepared by Nelly Biondi and Gatan Lafortune; Chapter 2 by
Nelly Biondi, Marion Devaux, Michele Cecchini and Franco Sassi (Jerome Silva from the OECD
Environment Directorate and Joao Matias from the European Monitoring Centre for Drugs and Drug
Addiction also provided useful comments); Chapter 3 by Gatan Lafortune, Galle Balestat, Liliane
Moreira, Nelly Biondi, Michael Schoenstein and Marie-Clmence Canaud (Christos Kazassis, a Greek
Healthcare Technology Expert, also provided useful comments on the indicator related to medical
technologies); Chapter 4 by Caroline Berchet and Nelly Biondi, under the supervision of Ian Forde and
Niek Klazinga; Chapter 5 by Marion Devaux, Gatan Lafortune, Yuki Murakami and Nelly Biondi; and
Chapter 6 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 (Giuliano Amerini,
Hartmut Buchow, Margarida Domingues de Carvalho and Orestis Tsigkas), WHO Headquarters
(Chandika Indikadahena, Veneta Cherilova and Nathalie Van de Maele) and WHO Europe
(Ivo Rakovac and Natela Nadareishvili) who have contributed to the collection and validation of the
data from these two joint questionnaires, to ensure that they meet the highest standards of quality
and comparability. Most of the data in Chapter 1 come from the Eurostat Statistics Database; sincere
thanks to colleagues from Eurostat (Anke Weber, Hartmut Buchow and Jakub Hrkal) for making sure
that the most recent data would be available in time for this publication.
This publication benefited from comments from Valrie Paris and Francesca Colombo in the
OECD Health Division. Many useful comments were also received from Stefan Schreck and Fabienne
Lefebvre from the European Commission (DG SANCO, Health Information Unit), as well as from
several officials from other DG SANCO Units, DG Employment and DG Economic and
Financial Affairs.
TABLE OF CONTENTS
Table of contents
Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Readers guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
Chapter 1. Health status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.1. Life expectancy and healthy life expectancy at birth . . . . . . . . . . . . . . . . . . . . .
1.2. Life expectancy and healthy life expectancy at age 65 . . . . . . . . . . . . . . . . . . . .
15
16
18
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20
22
24
26
28
30
32
34
36
38
40
1.14. Diabetes prevalence and incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.15. Dementia prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42
44
Chapter 2. Determinants of health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.1. Smoking among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2. Alcohol consumption among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3. Use of illicit drugs among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4. Fruit and vegetable consumption among adults . . . . . . . . . . . . . . . . . . . . . . . . .
2.5. Overweight and obesity among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.6. Air pollution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47
48
50
52
54
56
58
Chapter 3. Health care resources and activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.1. Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2. Consultations with doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3. Nurses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.4. Medical technologies: CT scanners and MRI units . . . . . . . . . . . . . . . . . . . . . . .
3.5. Hospital beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.6. Hospital discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.7. Average length of stay in hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.8. Cardiac procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.9. Cataract surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.10. Hip and knee replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.11. Pharmaceutical consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
61
62
64
66
68
70
72
74
76
78
80
82
TABLE OF CONTENTS
Chapter 4. Quality of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.1. Avoidable hospital admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2. Prescribing in primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.3. Mortality following acute myocardial infarction . . . . . . . . . . . . . . . . . . . . . . . . .
4.4. Mortality following stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
85
86
88
90
92
4.5. Procedural or postoperative complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

4.6. Screening, survival and mortality for cervical cancer. . . . . . . . . . . . . . . . . . . . . 96
4.7. Screening, survival and mortality for breast cancer . . . . . . . . . . . . . . . . . . . . . . 98
4.8. Screening, survival and mortality for colorectal cancer . . . . . . . . . . . . . . . . . . . 100
4.9. Childhood vaccination programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.10. Influenza vaccination for older people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Chapter 5. Access to care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1. Coverage for health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2. Out-of-pocket medical expenditure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3. Geographic distribution of doctors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.4. Unmet health care needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.5. Waiting times for elective surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
107
108
110
112
114
116
Chapter 6. Health expenditure and financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6.1. Health expenditure per capita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.2. Health expenditure in relation to GDP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.3. Health expenditure by function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.4. Pharmaceutical expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.5. Financing of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.6. Trade in health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
119
120
122
124
126
128
130
Statistical annex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
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Health at a Glance: Europe 2014

OECD 2014
Executive summary
uropean countries have achieved significant gains in population health, but there remain large
inequalities in health status both across and within countries. Life expectancy at birth in European
Union (EU) member states has increased by more than five years on average since 1990, although the
gap between those countries with the highest and lowest life expectancies remains around eight
years. There are also persistently large inequalities within countries among people from different
socio-economic groups, with individuals with higher levels of education and income enjoying better
health and living several years longer than those more disadvantaged. These disparities are linked to
many factors, including some outside health care systems, such as the environment in which people
live, individual lifestyles and behaviours, and differences in access to and quality of care.
Health at a Glance: Europe 2014 presents the most recent data on health status, risk factors to
health, and access to high-quality care in all 28 EU member states, candidate countries (with the
exception of Albania due to limited data availability) and European Free Trade Association (EFTA)
countries. The selection of indicators is based mainly on the European Core Health Indicators (ECHI),
developed by the European Commission. This edition includes a new chapter on access to care,
assessing where possible the impact of the economic crisis on financial barriers, geographic barriers
and waiting times.
Life expectancy has continued to increase, but inequalities persist

Life expectancy at birth in EU member states increased by over five years between 1990 and 2012 to
79.2 years. However, the gap between the highest life expectancies (Spain, Italy and France) and the
lowest (Lithuania, Latvia, Bulgaria and Romania) has not fallen since 1990.
Life expectancy at age 65 has also increased substantially, averaging 20.4 years for women and
16.8 years for men in the European Union in 2012. Life expectancy at age 65 varies by about five
years between those countries with the highest life expectancies and those with the lowest.
Highly educated men and women are likely to live several years longer and to be in better health.
For example, in some central and eastern European countries, 65-year-old men with a high level of
education can expect to live four to seven years longer than those with a low education level.
On average across EU countries, women live six years longer than men. This gender gap is one year
only for healthy life years (defined as the number of years of life free of activity limitation).
Assessing the impact of the economic crisis on health

The crisis has had a mixed impact on population health and mortality. While suicide rates
increased slightly at the start of the crisis, they seem to have returned to pre-crisis levels. Mortality
from transport accidents declined more rapidly in the years following the crisis than in prior years.
The exposure of the population to air pollution also fell following the crisis, although some air
pollutants seem to have risen since then.
The economic crisis might also have contributed to the long-term rise in obesity. One in six adults
on average across EU member states was obese around 2012, up from one in eight around 2002.
Evidence from some countries shows a link between financial distress and obesity: regardless of
EXECUTIVE SUMMARY
their income or wealth, people who experience periods of financial hardship are at increased risk.
Obesity also tends to be more common among disadvantaged groups.
Health spending has fallen or slowed following the economic crisis

Between 2009 and 2012, expenditure on health in real terms (adjusted for inflation) fell in half of
the EU countries and significantly slowed in the rest. On average, health spending decreased by
0.6% each year, compared with annual growth of 4.7% between 2000 and 2009. This was due to cuts
in health workforce and salaries, reductions in fees paid to health providers, lower pharmaceutical
prices, and increased patient co-payments.
While health spending has grown at a modest rate in 2012 in several countries (including Austria,
Germany and Poland), it has continued to fall in Greece, Italy, Portugal and Spain, as well as in the
Czech Republic and Hungary.
Universal health coverage has protected access to health care

Most EU countries have maintained universal (or near-universal) coverage for a core set of health
services, with the exception of Bulgaria, Greece and Cyprus where a significant proportion of the
population is uninsured. Still, even in these countries, measures have been taken to provide
coverage for the uninsured.
Ensuring effective access to health care requires the right number, mix and distribution of health
care providers. The number of doctors and nurses per capita has continued to grow in nearly all
European countries, although there are concerns about shortages of certain categories of doctors,
such as general practitioners in rural and remote regions.
On average across EU countries, the number of doctors per capita increased from 2.9 doctors per
1 000 population in 2000 to 3.4 in 2012. This growth was particularly rapid in Greece (mostly before
the economic crisis) and in the United Kingdom (an increase of 50% between 2000 and 2012).
In all countries, the density of doctors is greater in urban regions. Many European countries provide
financial incentives to attract and retain doctors in underserved areas.
Long waiting times for health services is an important policy issue in many European countries.
There are wide variations in waiting times for non-emergency surgical interventions.
Quality of care has improved in most countries, but disparities persist

Progress in the treatment of life-threatening conditions such as heart attack, stroke and cancer has led
to higher survival rates in most European countries. On average, mortality rates following hospital
admissions for heart attack fell by 40% between 2000 and 2011 and for stroke by over 20%. Lower
mortality rates reflect better acute care and greater access to dedicated stroke units in some countries.
Cancer survival has improved in most countries, including cervical cancer, breast cancer and
colorectal cancer. But cervical cancer survival was over 20% lower in Poland compared with Austria
and Sweden, while breast cancer survival was almost 20% lower in Poland than in Sweden.
The quality of primary care has also improved in most countries, as shown by the reduction in
avoidable hospital admissions for chronic diseases such as asthma and diabetes. Still, there is
room to improve primary care to further reduce costly hospital admissions.
Population ageing will continue to increase demands on health and long-term care systems in the
years ahead. The DG for Economic and Financial Affairs projected in 2012 that public spending on health
care would increase by 1% to 2% of GDP on average across EU countries between 2010 and 2060, and there
would be a similar growth in public spending on long-term care. Amid tight budget constraints, the
challenge will be to preserve access to high-quality care for the whole population at an affordable cost.
10
READERS GUIDE
Readers guide
ealth at a Glance: Europe 2014 presents key indicators of health and health systems in 35 European
countries, including the 28 European Union member states, four candidate countries* and three
European Free Trade Association countries. This third edition builds on the two previous in 2010
and 2012 and presents a greater number of indicators included in the list of European Core Health
Indicators (ECHI, www.echim.org/), reflecting progress in data availability and comparability.
Complemeting the chapter on quality of care which was added in 2012, this 2014 edition includes a
new chapter on access to care, based mainly on ECHI indicators, complemented with some additional
indicators related to financial access and geographic access.
The data presented in this publication are mostly official national statistics and have in many
cases been collected through questionnaires administered by the OECD, Eurostat and WHO. Some
data have also been collected through European surveys co-ordinated by Eurostat, notably the
European Union Statistics on Income and Living Conditions Survey (EU-SILC) and the first wave of the
European Health Interview Survey (EHIS). The data have been validated by the three organisations to
ensure that they meet standards of data quality and comparability. 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

This publication is structured around six chapters:
Chapter 1 on Health Status highlights the variations across countries in life expectancy and healthy
life expectancy, and also presents more specific indicators on different causes of mortality and
morbidity, including both communicable and non-communicable diseases.
Chapter 2 on Determinants of Health focuses mainly on non-medical determinants of health related
to modifiable lifestyles and behaviours, such as smoking and alcohol drinking, the consumption of
illegal drugs, nutrition habits, and overweight and obesity. It also includes an indicator on air
pollution, as another important factor affecting health.
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, the availability of different types of
equipment used for diagnosis or treatment, and the provision of a range of services to treat various
health problems.
Chapter 4 on Quality of Care provides comparisons on care for chronic and acute conditions, cancers
and communicable diseases. The chapter also includes some indicators related to patient safety,
building on the data developmental work carried out under the OECD Health Care Quality
Indicators project.
Chapter 5 is a new chapter on Access to Care in this European edition, which presents a small set of
indicators related to financial access to care, geographic access, and timely access (waiting times),
as well as unmet care needs for medical care and dental care.
* Albania has become a EU candidate country on 27 June 2014, but is not included in this publication due to
limited data availability when this report was prepared.
11
READERS GUIDE
Chapter 6 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 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 the EU member states presented (up to 28, 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 Statistics 2014 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 the 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
DG SANCOs ECHI 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 which are used to calculate rates per capita in this publication come from the Eurostat
Demographics Database. The data were extracted in June 2014, and relate to mid-year estimates
(calculated as the average between the beginning and end of the 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.
12
READERS GUIDE
Country ISO codes

Austria
AUT
Lithuania
LTU
Belgium
BEL
Luxembourg
LUX
Bulgaria
BGR
Malta
MLT
Croatia
HRV
Montenegro
MNE
Cyprus1, 2
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
Slovak Republic
SVK
Germany
DEU
Slovenia
SVN
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.
2. 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.
13

OECD 2014
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
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 improved lifestyle and better education, as
well as greater access to quality health services.
Life expectancy at birth across the 28 EU member states
reached 79.2 years on average in 2012, an increase of
5.1 years since 1990 (Figure 1.1.1). Spain, Italy and France
lead a large group of about two-thirds of EU countries in
which life expectancy at birth now exceeds 80 years. Life
expectancy remained below 80 years in central and eastern
European countries as well as in the three Baltic countries.
Since 1990, there have been significant increases in life
expectancy in all EU member states, due mainly to a
marked reduction in mortality from cardiovascular
diseases, particularly among people aged 50 to 65. Estonia
is the country that has achieved the largest gains since 1990
(around seven years), followed by the Czech Republic
(6.6 years), while Lithuania and Bulgaria have achieved
much smaller gains (around three years).
Life expectancy for women on average across EU member
states reached 82.2 years in 2012, compared with 76.1 years
for men (Figure 1.1.2). For women, life expectancy was
highest in Spain (85.5 years), while it was highest in Sweden
for men (79.9 years). The gap between the EU member states
with the highest and lowest life expectancies was 7.6 years
for women and 11.5 years for men.
The gender gap in life expectancy has decreased since
1990, coming down from 7.2 to 6.1 years in 2012. The
narrowing of this gender 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. However,
there remain large variations in the gender gap in life
expectancy across countries, with the smallest gap in the
Nordic countries (Sweden, Denmark, Norway and Iceland),
the Netherlands and the United Kingdom (about four years
only), with the largest gap being in the Baltic countries
where life expectancy for men continues to be over ten
years shorter than for women.
In a c o ntex t of in creasing life expectancy and
population ageing, healthy life years (HLY) has been
endorsed as an important European indicator to monitor
whether the extra years of life are lived in good health. The
current main indicator of HLY is a measure of disability-free
life expectancy which indicates how long people can expect
to live without disability. On average across EU member
states, HLY at birth in 2012 was 62.3 years for women and
61.3 years for men (Figure 1.1.2). It was highest in Malta and
Sweden for both men and women (above 70 years). The
shortest HLY at birth was in Estonia, the Slovak Republic
and Latvia for men, and in the Slovak Republic and Portugal
for women. In Malta and Sweden, women can expect to live
more than 85% of their life expectancy without limitations
16
in their usual activities. For men, the proportion of life in

good health was even higher at around 90%.
In contrast to the 6.1 year gap in life expectancy at birth
on average in EU member states, the gender gap in HLY was
only one year in 2012. In seven countries, the healthy life
years for men was in fact greater than for women, with the
greatest gap favouring men in the Netherlands (4.6 more
HLY for men). The European Innovation Partnership on
Active and Healthy Ageing, which is part of the Europe
2020 initiative, has set an objective of increasing the
average number of healthy life years by two years by 2020
(European Commission, 2011).
Definition and comparability

Life expectancy at birth measures how long, on
average, people would live based on a given set of agespecific 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 long-term activity limitation, being
equivalent to disability-free life expectancy. HLY are
calculated annually by Eurostat using the Sullivan
method which is based on life table data and agespecific period prevalence data on long-term activity
limitations. The underlying health measure is the
Global Activity Limitation Indicator (GALI), which
measures limitation in usual activities, and comes
from the 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).
References
European Commission (2011), Europe 2020 Flagship Initiative
Innovation Union, Directorate-General for Research and
Innovation, European Commission, Brussels.
Jagger, C. et al. (2010), The Global Activity Limitation Indicator (GALI) Measured Function and Disability Similarly
across European Countries, Journal of Clinical Epidemiology, Vol. 63, pp. 892-899.
1.1. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT BIRTH
1.1.1. Life expectancy at birth, 1990 and 2012

2012
1990
74.9
76.4
74.9
81.5
77.6
83.0
82.8
74.1
74.4
74.1
75.3
74.5
76.3
76.9
76.7
78.1
77.3
80.2
79.2
80.5
80
80.3
80.7
80.6
80.9
80.7
81.0
80.9
81.1
81.0
81.2
81.1
81.8
81.5
82.4
82.1
82.5
Years
90
70
S w el
i t z and
er
la
No nd
rw
a
M Tur y
on ke
te y
ne
FY
g
R
of S ro
M er b
ac ia
ed
on
ia
Ic
Sp
ai
n
It a
Fr l y
an
c
Lu S we e
xe d e
m n
Ne bo
t h ur
er g
la
n
C y ds
pr
Au us
Un G s tr i
i t e er m a
d
K i any
ng
do
Ir e m
la
nd
M
al
Gr t a
ee
Fi ce
nl
Po and
r tu
Be gal
lg
Sl ium
ov
D e eni a
nm
ar
k
Cz EU
ec 28
h
Re
C r p.
oa
t
Po i a
la
E nd
Sl s to
ov ni
ak a
R
H u e p.
ng
Ro a r y
m
a
Bu ni a
lg
ar
i
La a
Li t vi
th a
ua
ni
a
60
Source: Eurostat Statistics Database completed with data from OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en.
1 2 http://dx.doi.org/10.1787/888933155343
1.1.2. Life expectancy (LE) and healthy life years (HLY) at birth, by gender, 2012
LE with activity limitation
HLY
Life expectancy
Women
Men
Spain
France
Italy
Luxembourg
Finland
Sweden
Austria
Portugal
Cyprus
Greece
Germany
Slovenia
Ireland
Belgium
Netherlands
Malta
United Kingdom
EU28
Denmark
Estonia
Czech Republic
Poland
Croatia
Slovak Republic
Lithuania
Latvia
Hungary
Romania
Bulgaria
85.5
85.4
84.8
83.8
83.7
83.6
83.6
83.6
83.4
83.4
83.3
83.3
83.2
83.1
83.0
83.0
82.8
82.2
82.1
81.5
81.2
81.1
80.6
79.9
79.6
78.9
78.7
78.1
77.9
71.4
75.1
72.7
73.9
72.5
68.4
68.9
71.6
71.0
70.9
Switzerland
Iceland
Norway
Turkey
Montenegro
Serbia
FYR of Macedonia
84.9
84.3
83.5
80.5
78.4
77.5
76.9
90
Years
79.5
78.7
79.8
79.1
77.7
79.9
78.4
77.3
78.9
78.0
78.6
77.1
78.7
77.8
79.3
78.6
79.1
76.1
78.1
60
30
80.6
81.6
79.5
74.8
74.3
72.3
73.0
30
60
90
Years
Source: Eurostat Statistics Database.
1 2 http://dx.doi.org/10.1787/888933155343
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.
In 2012, the life expectancy at age 65 on average in
EU member states was 18.9 years: 16.8 years for men and
20.4 years for women (Figure 1.2.1). As for life expectancy at
birth, France had the highest life expectancy at age 65 for
women (23.4 years), but also for men (19.1 years). Life
expectancy at age 65 was lowest in Bulgaria for women
(17.3 years) and Latvia for men (13.6 years).
The gender gap in life expectancy at age 65 on average
across EU countries was 3.6 years in 2012, unchanged since
1990. Cyprus had the smallest gender gap (2.5 years), while
the three Baltic countries (Estonia, Latvia and Lithuania)
had the largest gap (around five years).
Since 1990, there have been significant gains in life
expectancy at age 65 in all EU member states. Ireland achieved
the largest gains (4.4 years), while the gains in Lithuania and
Bulgaria were smaller (less than two years).
Looking ahead, Eurostat projects that life expectancy at
age 65 will continue to increase in the coming decades to
reach 22.4 years for men and 25.6 for women on average
in 2060 (European Commission, 2012). This increase
combined with the trend reduction in fertility rates will
pose considerable challenges associated with an ageing
society, possibly reducing labour market participation rates
and increasing pressures on pensions and health and longterm care systems. Whether longer life expectancy is
accompanied by good health and functional status among
ageing populations has therefore important implications
on possibilities to extend working lives and the demands
for health and long-term care.
Healthy life years (HLY) at age 65 in 2012 on average in
EU member states was similar for men and women, being
8.5 years for men and 8.7 years for women. It was greatest
in the Nordic countries (Sweden, Denmark, Norway and
Iceland) and in Malta, and shortest in the Slovak Republic
for both men and women (Figure 1.2.1). Men and women at
age 65 in Sweden can expect to live about three-quarter of
their remaining years of life without limitations in their
usual activities, while in the Slovak Republic this
proportion is less than a quarter.
There is almost no gender gap in HLY compared with
the gap of 3.6 years in life expectancy. This reflects the fact
that a greater proportion of women report some activity
limitations. In nine EU countries, the number of healthy life
years for men at age 65 was in fact greater than for women.
L if e ex p e ct a n cy a t ag e 6 5 ye a r s a l s o var i e s by
educational status (Figure 1.2.2). For both men and women,
highly educated people are likely to live longer (Corsini,
2010). Differences in life expectancy by education level are
particularly large in central and eastern European
countries, especially for men. In the Czech Republic,
18
65-year-old men with a high level of education can expect

to live seven years longer than those with a low education
level. By contrast, differences in life expectancy by
education level are narrow in the Nordic countries, Malta
and Portugal.
The relationship between life expectancy and HLY at
age 65 is not clear-cut (Figure 1.2.3). 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. Two country groupings are apparent, with central
and eastern European countries and Baltic countries having
both lower life expectancy and HLY than other countries.

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 long-term activity limitation, being equivalent to
disability-free life expectancy. HLY are calculated
annually by Eurostat for each EU country based on life
table data and age-specific prevalence data on longterm activity limitations. The underlying health
m e a s u re i s t h e G l o b a l A c t iv i t y L i m i t a t i o n
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).
References
Corsini, V. (2010), Highly Educated Men and Women Likely
to Live Longer: Life Expectancy by Educational Attainment, Eurostat Statistics in Focus 24/2010, European
Commission, Luxembourg.
European Commission (2012), The 2012 Ageing Report: Economic and Budgetary Projections for the 27 EU Member States
(2010-2060), European Commission, Brussels.
Jagger, C. et al. (2010), The Global Activity Limitation Indicator (GALI) Measured Function and Disability Similarly
across European Countries, Journal of Clinical Epidemiology, Vol. 63, pp. 892-899.
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, 2012
LE with activity limitation
HLY
Life expectancy
Women
Men
France
Spain
Italy
Finland
Luxembourg
Austria
Belgium
Portugal
Germany
Ireland
Slovenia
Sweden
Greece
Malta
Netherlands
United Kingdom
EU28
Cyprus
Estonia
Denmark
Poland
Czech Republic
Lithuania
Croatia
Latvia
Slovak Republic
Hungary
Romania
Bulgaria
23.4
22.8
22.1
21.6
21.4
21.3
21.3
21.3
21.2
21.1
21.1
21.1
21.0
21.0
21.0
20.9
20.4
20.4
20.3
20.2
19.9
19.2
19.2
18.7
18.5
18.5
18.1
17.7
17.3
19.5
17.3
16.5
15.9
20
14.8
17.5
15.4
15.7
14.1
15.0
13.6
14.6
14.3
14.5
13.9
Switzerland
Iceland
Norway
Turkey
Montenegro
Serbia
FYR of Macedonia
22.3
21.5
21.0
25
Years
19.1
18.7
18.5
17.8
18.4
18.1
17.7
17.6
18.2
18.0
17.1
18.5
18.1
17.6
18.0
18.5
16.8
17.9
15
10
19.3
20.1
18.3
16.0
15.2
14.0
13.9
10
15
20
25
Years
1 2 http://dx.doi.org/10.1787/888933155356
1.2.2. Life expectancy gaps between people with high

and low level of education at 65, 2010
Men
0.6
0.7
0.8
0.6
1.1
1.1
1.4
1.2
1.5
0.7
Malta (2008)
Portugal
Sweden
Denmark
Finland
Romania (2009)
Italy (2009)
EU14
Poland
Hungary
Bulgaria
Croatia
Estonia
Slovenia
Czech Republic
1.1
1.1
1.3
1.1
1.0
SWE
MLT
12
1.9
1.9
10
2.7
2.8
2.6
1.5
1.8
NLD
BGR
HRV
HUN
ROU
LTU
LVA
EU
POL
CYP
SVN
PRT
LUX
IRL
GBR
AUT
FIN
GRC
FRA
ESP
ITA
DEU
EST
4
7.0
2.3
CZE
3.5
3.5
3.8
3.9
4.2
SVK
2.0
1.5
DNK
BEL
1.8
HLY
16
14
2.3
Norway
FYR of Macedonia
Women
1.2.3. Relationship between life expectancy (LE)

and healthy life years (HLY) at 65, 2012
R = 0.29
3.3
0
4
8
Years
1 2 http://dx.doi.org/10.1787/888933155356
15
17
19
21
23
1 2 http://dx.doi.org/10.1787/888933155356
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 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 2011, there were large variations in age-standardised
mortality rates for all causes of death across European
countries. Death rates were lowest in northern, western
and southern European countries, especially in France,
Spain, Italy as well as Switzerland at around 900 deaths or
less per 100 000 population (Figure 1.3.1). Rates were
highest in Baltic and central and eastern European
countries: Bulgaria, Romania, Latvia, Lithuania, Hungary
and the Slovak Republic had age-standardised rates almost
twice those of the lowest countries at around 1 500 deaths
or more per 100 000 population.
A significant gender gap exists in mortality rates in all
countries (Figure 1.3.1). Across all EU member states, the
male mortality rate was, on average, nearly 60% higher than
the female rate in 2011. But larger differences exist in some
countries: in Estonia, Lithuania and Latvia, mortality rates
among men were almost two times greater than among
women. The gender gap is smaller but still significant in
Cyprus and the United Kingdom (a gap of less than 40%).
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 7.5 years for women (between France and Bulgaria) and
around 11 years for men (between Italy/Sweden on the one
hand and Latvia/Lithuania on the other hand).
Although mortality rates in Baltic and central and
eastern European countries are still relatively high,
significant reductions have occurred in a number of these
countries since 2000 (Figure 1.3.2). Mortality rates in Estonia
have fallen by 27%, a decline that is greater than the EU
average of 18%. In Bulgaria, mortality rates have declined at
about the same pace as the reduction in EU countries, so the
gap has remained constant. By contrast, in Lithuania, the
reduction in overall mortality rates have been more modest
(only 8% reduction) since 2000; most of this reduction has
been achieved since 2007.
Mortality rates have also come down in France and
Germany, but at a slightly faster pace in France, thereby
widening the gap slightly between these two countries.
In 2011, the gap in mortality rates between France and
Germany was particularly large for cardiovascular diseases.
20
Cardiovascular diseases (including ischaemic heart

diseases, stroke and other diseases of the circulatory system) were the leading cause of death in Europe in 2011,
accounting for almost 40% of all deaths in EU countries (see
Indicator 1.4).
Cancer was the second leading cause of death,
accounting for 26% of all deaths in EU countries in 2011,
with lung cancer, colon cancer and prostate cancer being
the main causes of cancer death among men, while breast
cancer, colon cancer and lung cancer were the main three
causes of cancer death among women (see Indicator 1.5).
External causes of death (which include accidents,
suicides and other causes of death) were responsible for
around 7% of all deaths in EU countries in 2011 (see
Indicators 1.6 and 1.7).
Most deaths (80%) in EU countries occur after the age
of 65, but still one-in-five deaths are premature deaths
occurring before age 65. While the main cause of death
among men aged under 65 years is cardiovascular diseases,
women below 65 are two times more likely to die from some
types of cancer than from cardiovascular diseases (Buchow
et al., 2012).

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
age-standardised to the revised European standard
population adopted by Eurostat in 2012, to remove
variations arising from differences in age structures
across countries and over time. The change in the
population structure in this edition of Health at a
Glance Europe compared with previous editions has led
to a general increase in the standardised rates for all
countries.
Deaths from all causes include ICD-10 codes A00-Y89,
excluding S00-T98.
Reference
Buchow, H. et al. (2012), Circulatory Diseases Main Causes
of Death for Persons Aged 65 and More in Europe, 2009,
Eurostat Statistics in Focus 7/2012, European Commission,
Luxembourg.
1.3. MORTALITY FROM ALL CAUSES
1.3.1. Mortality rates from all causes of death, 2011

Women
Men
Total
Age-standardised rates per 100 000 population

2 500
2 000
1 500
1 000
500
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Sp
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1 2 http://dx.doi.org/10.1787/888933155362
1.3.2. Trends in mortality rates from all causes of death, selected EU member states, 2000-11
Estonia
Bulgaria
France
Germany
Lithuania
EU28

2 200
2 000
1 800
1 600
1 400
1 200
1 000
800
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
1 2 http://dx.doi.org/10.1787/888933155362
21
1.4. MORTALITY FROM HEART DISEASE AND STROKE
Cardiovascular diseases are the main cause of mortality

in nearly all EU member states, accounting for almost 40%
of all deaths in the region in 2011. 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 around 60% of all cardiovascular deaths,
and caused more than one quarter of all deaths in
EU member states in 2011.
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 around 18% of all deaths in EU member
states in 2011. Mortality from IHD varies considerably
however: Baltic countries and central and eastern European
countries have the highest IHD mortality rates, with
Lithuania, Latvia, the Slovak Republic, Hungary, the
Czech Republic and Estonia reporting over 350 deaths per
100 000 population (Figure 1.4.1). Besides the Netherlands,
Belgium, Luxembourg and Denmark, the countries with the
lowest IHD mortality rates were located in southern Europe
with France, Portugal, Spain, Greece and Italy having rates
lower than 115 deaths per 100 000 population. This supports
the view that some underlying risk factors, such as diet,
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 2011 were 70%
higher in men than in women. The disparity was greatest in
France, Greece, Spain, the Netherlands, Belgium, Finland,
the United Kingdom and Luxembourg, with male rates
more than two times higher. The gap was lowest in the
Slovak Republic and Croatia, with a gap of less than 40%.
Since 2000, IHD mortality rates have declined in all
countries (Figure 1.4.3). The decline has been particularly
strong in countries such as the Netherlands and the
United Kingdom. Declining tobacco consumption
contributed significantly to reducing the incidence of IHD,
and consequently to reducing mortality rates (see
Indicator 2.1). Improvements in medical care have also
played a role (OECD, forthcoming; see also Indicator 3.8
Cardiac procedures and Indicator 4.3 In-hospital
mortality following acute myocardial infarction). A small
number of countries, however, have seen little or no decline
since 2000. For example, declines in Lithuania and Hungary
have been very modest.
22
Stroke was the underlying cause for about 11% of all

deaths in EU countries in 2011. Stroke is 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. As with IHD, there are large
variations in stroke mortality rates across countries
(Figure 1.4.2). Again, the rates are highest in Baltic countries
and central and eastern European countries, including
Bulgaria, Romania, Latvia, Lithuania, and Croatia, with
more than 200 deaths per 100 000 population. They were
the lowest in France, the Netherlands, Austria, Spain,
Belgium as well as Switzerland.
Since 2000, stroke mortality has decreased in nearly all
EU member states. Rates have declined by 50% or more in
Estonia and Austria (Figure 1.4.4). However, the decline has
been very moderate in other countries such as Lithuania
and Bulgaria. 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
(OECD, forthcoming; see also Indicator 4.4 In-hospital
mortality following stroke).

countries.
Deaths from ischemic heart disease relate to ICD-10
codes I20-I25, and cerebro-vascular disease to I60-I69.
References
OECD (forthcoming), Cardiovascular Disease and Diabetes:
Policies for Better Health and Quality of Care, OECD
Publishing, Paris.
1.4. MORTALITY FROM HEART DISEASE AND STROKE
1.4.1. Ischemic heart disease, mortality rates, 2011

Men
France
Portugal
Netherlands
Spain
Belgium
Luxembourg
Denmark
Greece
Italy
Slovenia
Cyprus
United Kingdom
Germany
Sweden
Poland
Ireland
Austria
Bulgaria
EU28
Finland
Malta
Croatia
Romania
Estonia
Czech Republic
Hungary
Slovak Republic
Latvia
Lithuania
Women
Men
86
35
92
51
108
51
114
54
123
59
138
69
136
72
146
67
157
87
179
90
175
89
184
90
199
114
212
113
233
127
241
132
258
150
261
157
285
167
340
165
344
199
369
265
501
458
507
518
698
788
481
79
88
103
125
158
166
188
238
93
102
102
117
116
120
137
138
140
145
142
132
135
144
147
146
140
158
196
194
231
247
192
202
222
290
355
368
289
295
49 56
89
70
88
71
Switzerland
Norway
Iceland
FYR of Macedonia
200
400
600
800
1 000
Women
45 60
67
62
72
61
74
60
75
64
72
66
74
71
85
71
80
74
89
74
96
77
86
85
104
81
104
85
France
Netherlands
Austria
Spain
Belgium
Germany
United Kingdom
Denmark
Ireland
Sweden
Luxembourg
Cyprus
Finland
Italy
Estonia
Malta
Slovenia
EU28
Poland
Portugal
Greece
Czech Republic
Hungary
Slovak Republic
Croatia
Lithuania
Latvia
Romania
Bulgaria
425
287
288
303
335
377
369
Switzerland
Norway
FYR of Macedonia
Iceland
1.4.2. Stroke, mortality rates, 2011
383
345
100
200
300
400
500
1 2 http://dx.doi.org/10.1787/888933155375
1 2 http://dx.doi.org/10.1787/888933155375
1.4.3. Trends in ischemic heart disease mortality rates,

selected EU member states, 2000-11
1.4.4. Trends in stroke mortality rates, selected

EU member states, 2000-11
France
Hungary
Lithuania
Austria
Bulgaria
Estonia
Netherlands
United Kingdom
EU28
France
Lithuania
EU28

700

400
350
600
300
500
250
400
200
300
150
200
100
100
0
2000
50
2002
2004
2006
2008
2010
1 2 http://dx.doi.org/10.1787/888933155375
0
2000
2002
2004
2006
2008
2010
1 2 http://dx.doi.org/10.1787/888933155375
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 24% of all deaths in 2011. In 2011, cancer
mortality rates were lowest in Cyprus, Finland, Bulgaria,
Sweden and Switzerland, with rates at least 15% lower than
the EU average. They were highest in some central and
eastern European countries, including Hungary, Croatia,
the Slovak Republic, Slovenia and Denmark, with rates at
least 15% higher than the EU average (Figure 1.5.1).
Cancer mortality rates are higher for men than for
women in all countries. In 2011, the gender gap was
particularly wide in Lithuania, Spain, Latvia, Estonia, the
Slovak Republic, Portugal and Croatia, 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 is still by far the most common cause of
death from cancer among men (26.0%), followed by
colorectal cancer (11.5%) and prostate cancer (10.2%). Breast
cancer was the leading cause of death among women
(16.3%), followed by lung cancer (14.2%) and colorectal
cancer (12.3%) (Figure 1.5.2).
Lung cancer accounts for the greatest number of cancer
deaths among men in all EU member states, except in
Sweden (where prostate cancer is now the main cause of
cancer death among men). Smoking is the main risk factor
for lung cancer. In 2011, death rates from lung cancer
among men were highest in Hungary, Poland and Croatia,
with a rate more than 20% higher than the EU average
(Figure 1.5.3). These are all countries where smoking rates
among men are relatively high (see Indicator 2.1 Smoking
among adults). Death rates from lung cancer among men
were lowest in Portugal, Cyprus and in Nordic countries
(Sweden, Finland, Iceland and Norway), with the exception
of Denmark.
Breast cancer is the most common form of cancer
among women in all European countries (Ferlay et al., 2013;
see Indicator 1.13). 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. In 2011, mortality from breast cancer was lowest
in Spain, Portugal, Sweden, Finland and Poland, while it
was highest in Denmark, Malta, Ireland and Belgium (see
Indicator 4.7 in Chapter 4).
Colorectal cancer is an important cause of cancer death
among both men and women. There are several risk factors
for colorectal cancer, including age, a diet high in fat, and
genetic background. In 2011, colorectal cancer mortality
24
was lowest in Cyprus, Greece and Finland, while it was

highest in Hungary, the Slovak Republic and Croatia (see
Indicator 4.8 in Chapter 4).
Prostate cancer has become the most common cancer
among men in many European countries, particularly
among men aged 65 years and over, 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 2011 were lowest in Malta, Italy and
Romania, and highest in several central and eastern
European countries as well as in Nordic countries.
Death rates from all types of cancer among men and
women have declined at least slightly in most EU member
states since 2000, 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 in Baltic countries
(Latvia, Lithuania, Estonia) and central and eastern
European countries (Bulgaria, Croatia, Romania and the
Former Yugoslav Republic of Macedonia), where cancer
mortality has remained stable or increased.

to a general increase in the standardised rates for
all countries.
Deaths from all cancers relate to ICD-10 codes C00-C97,
lung cancer to C33-C34. 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.
References
Ferlay, J. et al. (2013), Cancer Incidence and Mortality Patterns in Europe: Estimates for 40 Countries in 2012,
European Journal of Cancer, Vol. 49, pp. 1374-1403.
1.5. MORTALITY FROM CANCER
1.5.1. All cancers mortality rates, men and women, 2011

Women
Men
Total

600
500
400
300
200
100
Sw
ed
en
Sp
ai
Gr n
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Po c e
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M
al
ta
Fr
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S
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an
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ia
Bu
lg
ar
an
nl
Fi
Cy
pr
us
1 2 http://dx.doi.org/10.1787/888933155381
1.5.2. Main causes of cancer deaths among men and women in EU countries, 2011
Men
Women
Stomach
Colorectal
Liver
Lung
Prostate
Others
Pancreas
Stomach
Colorectal
Pancreas
Breast
Ovary
Others
Lung
4.3
5.1
12.3
11.5
2.2
39.5
6.9
40.6
5.5
14.2
26.0
5.3
10.2
16.3
1 2 http://dx.doi.org/10.1787/888933155381
1.5.3. Lung cancer mortality rates

Women
Men
Total

160
140
120
100
80
60
40
20
a
Bu l t a
lg
ar
Au ia
st
Li ria
th
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Sp
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Sl 2 8
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Cz
G
re
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ng
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Ir e m
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B e nd
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Cr
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wi
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Po
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1 2 http://dx.doi.org/10.1787/888933155381
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
around 35 000 people in 2011. In addition to these deaths,
about 250 000 people were seriously injured in road
accidents. The direct and indirect financial costs of
transport accidents are substantial: estimations range from
1 to 3% of GDP annually (OECD/ITF, 2014).
The largest number of transport accidents occurs
among younger age groups with the risk of dying peaking at
ages 15-24, especially for men. Most fatal traffic injuries
occur in passenger vehicles, although other road users such
as motor cycles and scooters also face substantial risks. In
Greece, Italy and France, motorcyclists account for over 20%
of road transport accident deaths (OECD/ITF, 2014).
The average EU mortality rate due to transport accidents
was 7.7 per 100 000 population in 2011 (Figure 1.6.1). There
is great variation between EU countries with transport
accidents claiming more than four times as many lives per
100 000 population in Romania compared to the
United Kingdom. Fatalities were the highest in Romania,
Poland, Lithuania and Croatia in 2011, while they were the
lowest in the United Kingdom, Sweden and Ireland. In
Sweden, the most recent data indicate a further reduction
between 2011 and 2013. The sharp reduction in mortality
rates from road traffic accidents in Sweden can be
attributed to safer vehicles, better road infrastructure and
lower average speed (OECD/ITF, 2014).
In all EU member states, death rates from transport
accidents are much higher for males than for females. In
most countries, three to four times more men than women
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 as well
as vehicle design. In addition, the adoption of new laws and
regulations and the enforcement of these laws to improve
compliance with speed limits, seatbelt use and drinkdriving rules, have had a major impact on reducing the
burden of road transport accidents. As a result, death rates
due to transport accidents have decreased by more than
45% across the European Union since 2000 (Figure 1.6.2).
Spain, Luxembourg, Ireland, Estonia and Latvia have
reduced their mortality rates by 60% or more over this tenyear period. An important breakthrough was also achieved
in 2008 in Lithuania, with a growing awareness among the
citizens of road safety issues and the leading role of the
European Union in setting a target to reduce by 50% the
number of fatalities, between 2001 and 2011 (OECD/ITF,
2014). Death rates have also declined in Malta, Romania,
26
Croatia and Bulgaria, but at a slower pace (less than 25%

reduction). However, less success has been achieved in
saving lives among vulnerable road users than amongst car
occupants: reduction in deaths among pedestrians, cyclists
and motorcyclists have levelled-off and some increases
have been recorded.
In some countries hard-hit by the economic recession, the
downward trend has accelerated since 2008. For example, in
Greece, the number of death from transport accidents fell
from 1 722 in 2008 to 1 191 in 2012, a reduction of 30% in four
years (Hellenic Statistical Authority, 2014). One possible
explanation is that the economic crisis has reduced reliance
on motor vehicle use. However, this impact is likely to be
short-lived and over the longer term, effective road safety
policies will remain the primary contributor to reduced
mortality.

countries.
Deaths from transport accidents relate to ICD-10
codes V01-V99 and Y85. The majority of deaths from
transport accidents are due to road traffic accidents.
M o r t a l i t y ra t e s f r o m t r a n s p o r t a c c i d e n t s i n
Luxembourg are biased upward because of the large
volume of traffic in transit, resulting in a significant
proportion of non-residents killed.
References
Hellenic Statistical Authority (2014), Causes of Death: 2012,
Athens.
OECD/ITF (2014), IRTAD Road Safety 2014 Annual Report,
OECD/ITF, Paris.
1.6. MORTALITY FROM TRANSPORT ACCIDENTS
1.6.1. Transport accident mortality rates, 2011

Women
Men
Total

25
20
15
10
I
S w c ela
i t z nd
er
FY
la
n
R
of No d
M rw
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ed
on
ia
Un
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S w om
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e
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De and
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la
nd
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M
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Sp
Ge a in
Lu rm
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Fr g
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1 2 http://dx.doi.org/10.1787/888933155396
1.6.2. Trends in transport accident mortality rates, selected EU member states, 2000-11
Latvia
Lithuania
Romania
Spain
Sweden
EU28

30
25
20
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
1 2 http://dx.doi.org/10.1787/888933155396
27
1.7. SUICIDE
Suicide is a significant cause of death in many

EU member states, with approximately 60 000 such deaths
in 2011. Suicide rates vary widely across European
countries, with the lowest rates in southern European
countries Cyprus, Greece, Malta, Italy and Spain as well
as in the United Kingdom, and the highest rates in
Lithuania, Hungary, Slovenia and Latvia (where suicide
rates are more than 50% higher than the EU average). There
is an eight-fold difference between Lithuania and Cyprus,
the countries with the highest and lowest death rates. The
high suicide rates in Lithuania have been associated with a
range of factors, including rapid socioeconomic transition,
increasing psychological and social insecurity, and the
absence of a national suicide prevention strategy.
Death rates from suicide are around four times greater
for men than for women across the European Union
(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 risk also generally
increases with age.
Between 2000 and 2011, suicide rates have decreased by
20% across European countries, with pronounced declines
of over 35% in some countries such as Estonia and Latvia,
although suicide rates in these two countries remain above
the EU average (Figure 1.7.2). On the other hand, death rates
from suicides have increased in a few countries. In Portugal,
suicide rates increased mainly between 2000 and 2002, and
have remained fairly stable since then.
Previous studies have shown a strong link between
adverse economic conditions, higher levels of stress,
anxiety and depression, and higher levels of suicide
(e.g. Ceccherini-Nelli and Priebe, 2011; van Gool and
Pearson, 2014). Suicide rates rose at the start of the
economic crisis in a number of European countries, mainly
among men (Chang et al., 2013), but in many countries this
trend did not persist. In Greece, the absolute number of
deaths due to suicides increased substantially in recent
years, from 328 in 2007 to 477 in 2011 and 508 in 2012
(Hellenic Statistical Authority, 2014). This amounts to an
increase of over 50% during this five-year period.
Nonetheless, the suicide rate in Greece remains relatively
low compared with other countries, although this can be
explained at least partly by under-reporting.
The European Pact for Mental Health and Well-being,
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, and provision of support mechanisms
after suicide attempts and for those bereaved by suicide, such
as emotional support helplines (European Commission, 2009).

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. The number of suicides in certain countries
may be under-reported because of the stigma
associated with the act (for religious, cultural or other
reasons). The comparability of suicide data between
countries is also affected by a number of reporting
criteria, including how a persons 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.
Mortality rates have been age-standardised to the
revised European standard population adopted by
Eurostat in 2012, to remove variations arising from
differences in age structures across countries and
over time. The change in the population structure in
this edition of Health at a Glance Europe compared with
previous editions has led to a general increase in the
standardised rates for all countries.
Deaths from suicide relate to ICD-10 codes X60-X84
and Y870.
References
Ceccherini-Nelli, A. and S. Priebe (2011), Economic Factors
and Suicide Rates: Associations over Time in Four
Countries, Social Psychiatry and Psychiatric Epidemiology,
Vol. 46, No. 10, pp. 975-982.
Chang, S.S. et al. (2013), Impact of 2008 Global Economic
Crisis on Suicide: Time Trend Study in 54 Countries,
British Medical Journal, Vol. 347, f5239.
European Commission (2009), Policy Brief: Conclusions
from the EU Thematic Conference Preventing of Depression and Suicide-Making it Happen, Brussels.
Hellenic Statistical Authority (2014), Causes of Death: 2012,
Athens.
OECD (2014), Making Mental Health Count: The Social and
Economic Costs of Neglecting Mental Health Care, OECD
Health Policy Studies, OECD Publishing, Paris, http://
dx.doi.org/10.1787/9789264208445-en.
van Gool, K. and M. Pearson (2014), Health, Austerity and
Economic Crisis: Assessing the Short-term Impact in
OECD Countries, OECD Health Working Papers, No. 76,
OECD Publishing, http://dx.doi.org/10.1787/5jxx71lt1zg6-en.
Suicide rates can play an important role in signalling

weaknesses of mental health systems, in particular unmet
needs for care (OECD, 2014).
28
1.7. SUICIDE
1.7.1. Suicide mortality rates, 2011

Women
Men
Total

60
50
40
30
20
10
Gr
Cy
pr
us
ee
ce
M
al
ta
It a
Un
ly
i te S
p
d
K i a in
ng
d
Po om
Ne r tu
th ga
er l
la
nd
Sl
B
ov ul s
ak ga
Re r i a
pu
De blic
n
Lu m
xe ar
m k
bo
G e ur g
rm
a
Sw ny
ed
e
Ir e n
la
n
Ro d
m
an
ia
Cz
ec
EU
h
2
Re 8
pu
bl
Au ic
st
ri
Po a
la
n
Es d
to
ni
Cr a
oa
ti
Fr a
an
c
Fi e
nl
an
Be d
lg
iu
m
La
tv
Sl i a
ov
e
Hu ni a
ng
L i ar y
th
ua
FY
ni
R
a
of
M
ac
ed
on
Ic i a
el
a
N nd
S w or w
i t z ay
er
la
nd
1 2 http://dx.doi.org/10.1787/888933155405
1.7.2. Trends in suicide rates, selected European countries, 2000-11

Estonia
Greece
Hungary
Latvia
Portugal
EU28

40
35
30
25
20
15
10
5
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
1 2 http://dx.doi.org/10.1787/888933155405
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 2012, rates ranged from a low of
less than three deaths per 1 000 live births in Nordic countries
(with the exception of Denmark), Slovenia, Luxembourg, the
Czech Republic, Italy and Greece, up to a high of nine in
Romania and about eight in Bulgaria. Infant mortality rates
were also high in Turkey and the Former Yugoslav Republic of
Macedonia. The average across the 28 EU member states
in 2012 was four deaths per 1 000 live births.
Around two-thirds of the deaths that occur during the
first year of life are neonatal deaths (i.e., during the first
f ou r wee k s ) . B i r t h d e f e c t s , p re m a t u r i ty a n d o t h e r
conditions arising during pregnancy are the principal
factors contributing to neonatal mortality in European
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
increased in many countries (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 Sudden Infant Death Syndrome (SIDS),
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 around 25 deaths per
1 000 live births, to the current average of 4 (Figure 1.8.2).
This equates to a cumulative reduction of over 80% since
1970. Large reductions in infant mortality rates have
occurred in Slovenia, Italy, Greece and Portugal. The rates
have also come down in Romania and Bulgaria, but still
remain well above average. Between 2000 and 2010,
inequalities in infant mortality between EU member states
was reduced by 26% (European Union, 2013).
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 (OECD,
2010). 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 other factors also play an important role. A
body of research suggests that factors such as income
inequality and poverty, the social environment, and
30
individual lifestyles also influence infant mortality rates

(Schell et al., 2007).
Some research has suggested that the economic crisis
might have increased infant mortality rates in some of the
countries that were particularly hard-hit by the crisis,
either through its effect in deteriorating the socioeconomic
conditions of some mothers and their newborns, or
because of a reduction in pre-natal and post-natal care.
While the aggregate data presented here does not allow a
precise assessment of individual circumstances, there is no
evidence of an overall increase in infant mortality rates
after the crisis in countries such as Greece, Italy, Portugal
and Spain, although the share of low birth weight babies
has increased in Greece (see Indicator 1.9).

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. Some of the international variation
in infant and neonatal mortality rates may be due to
variations among countries in registering practices of
very premature infants. While some countries have
no gestational age or weight limits for mortality
registration, several countries apply a minimum
gestational age of 22 weeks (or a birth weight threshold
of 500 grams) for babies to be registered as live births
(Euro-Peristat, 2013).
References
Euro-Peristat (2013), European Perinatal Health Report: The
Health and Care of Pregnant Women and their Babies in 2010,
Luxembourg.
European Union (2013), Health Inequalities in the EU Final
Report of a Consortium, Consortium lead: Sir Michael
Marmot.
OECD (2010), Health Care Systems: Efficiency and Policy Settings,
OECD Publishing, Paris, http://dx.doi.org/10.1787/
9789264094901-en.
Schell, C.O. et al. (2007), Socioeconomic Determinants of
Infant Mortality: A Worldwide Study of 152 Low-,
Middle-, and High-income Countries, Scandinavian
Journal of Public Health, Vol. 35, pp. 288-297.
1.8. INFANT MORTALITY
1.8.1. Infant mortality rates, 2012 and decline 1970-2012

2012 (or nearest year)
Decline 1970-2012 (or nearest year)

Slovenia
Finland
Luxembourg
Sweden
Czech Republic
Italy
Greece
Spain
Austria
Germany
Portugal
Denmark
Cyprus
France
Ireland
Estonia
Croatia
Netherlands
Belgium
Lithuania
EU28
United Kingdom
Poland
Hungary
Malta
Slovak Republic
Latvia
Bulgaria
Romania
1.6
2.4
2.5
2.6
2.6
2.9
2.9
3.1
3.2
3.3
3.4
3.4
3.5
3.5
3.5
3.6
3.6
3.7
3.8
3.9
4.0
4.1
4.6
4.9
5.3
5.8
6.3
7.8
9.0
3.6
4.4
6.2
9.8
11.6
-5.5
-3.7
-5.3
-6.0
-6.0
-4.9
-5.4
-4.9
-7.2
-3.6
-5.1
-4.2
-4.4
-4.1
-5.8
-3.1
-4.4
-4.1
-4.7
-3.8
-5.3
-5.1
-4.0
-3.8
-2.6
-3.2
-4.3
Iceland
Norway
Switzerland
Montenegro
Serbia
FYR of Macedonia
Turkey
1.1
2.5
15
10
Deaths per 1 000 live births
-7.1
-4.4
-6.3
-3.8
-3.6
-5.6
-2
-4
-6
-8
Average annual rate of decline (%)
1 2 http://dx.doi.org/10.1787/888933155415
1.8.2. Infant mortality rates, selected European countries, 1970-2012

Bulgaria
Greece
Romania
Slovenia
EU28
Deaths per 1 000 live births

50
40
30
20
10
0
1970
1975
1980
1985
1990
1995
2000
2005
2010
1 2 http://dx.doi.org/10.1787/888933155415
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). Babies with
a birth weight under 1500 grams are termed very low birth
weight babies and are at the highest risk.
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.
Around one in 15 babies born in EU countries in 2012 or
6.8% of all births weighted less than 2 500 grams at birth
(Figure 1.9.1). A north-south gradient is evident for low
birth weight in Europe, in that the Nordic and Baltic countries
including Finland, Sweden, Iceland, Norway, Estonia, Latvia
and Lithuania reported the smallest proportions of low
weight births, with less than 5% of live births so defined.
Countries from southern and eastern Europe including
Cyprus, Greece, Hungary, Portugal, Romania and Bulgaria,
are at the other end of the scale with rates of low birth
weight infants above 8%. The proportion of low birth weight
among European countries varies by a factor of almost three.
Since 1980, and particularly after 1995, the prevalence of
low birth weight infants has increased in most European
countries (Figures 1.9.1 and 1.9.2). Portugal, Malta and
Greece have seen particularly large increases over the past
three decades. As a result, the proportion of low birth
weight babies in these countries is now above the European
average. These increases may be due to a number of factors,
including a rise in the number of multiple births with
increased risks of pre-term births and low birth weight
(partly linked to the rise in fertility treatments), older age of
mother 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. In Greece, the rise in the
proportion of low birth weight babies started well before the
crisis, in the mid-1990s, but has reached a peak in recent
years. Some researchers have suggested that the marked
increase in the number of low birth weight babies since
2008 may be linked to the economic crisis which has
resulted in higher unemployment rates and lower family
incomes (Kentikelenis, 2014).
By contrast, the proportion of low birth weight babies in
Poland and Hungary has declined since 1980, although it
remains relatively high and above the EU averag e
in Hungary.
different countries and population groups, and these need

to be taken into account when interpreting differences
(Euro-Peristat, 2013). 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 birth weight (Bakeo
and Clarke, 2006). A recent study (Pedersen et al., 2013) has
also shown that exposure to ambient air pollutants during
pregnancy is associated with restricted fetal growth and
that a substantial proportion of cases of low birth weight
may be prevented in Europe if urban air pollution was
reduced (see Indicator 2.6 Air pollution).

Low birth weight is defined by the World Health
Organization 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 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.
References
Bakeo, A.C. and L. Clarke (2006), Risk Factors for Low Birthweight Based on Birth Registration and Census Information, England and Wales, 1981-2000, Health Statistics
Quarterly, Vol. 30, pp. 15-21.
Euro-Peristat (2013), European Perinatal Health Report: The
Health and Care of Pregnant Women and their Babies in 2010,
Luxembourg.
Kentikelenis, A. (2014), Greeces Health Crisis: From
Austerity to Denialism, The Lancet, Vol. 383, No. 9918,
pp. 748-753.
Pedersen, M. et al. (2013), Ambient Air Pollution and Low
Birthweight: A European Cohort Study (ESCAPE), The
Lancet, Vol. 1, No. 9, pp. 695-704.
UNICEF and WHO (2004), Low Birthweight: Country, Regional
and Global Estimates, UNICEF, New York.
Despite the widespread use of a 2 500 gram limit for low

birth weight, physiological variations in size occur among
32
1.9. INFANT HEALTH: LOW BIRTH WEIGHT
1.9.1. Low birth weight infants, 1980 and 2012

2012
1980
% of newborns weighing less than 2 500 g

12
10
8
6
4
8.0
7.2
6.7
6.0
5.1
4.6
4.3
11.5
9.8
8.6
8.5
8.4
8.3
8.0
7.9
7.7
7.3
7.0
6.9
6.9
6.9
6.8
6.8
6.6
6.5
6.4
6.0
6.0
5.7
5.3
4.9
4.8
4.6
4.6
4.2
4.1
el
an
d
M N or
on w
te ay
ne
gr
o
F Y S w S er
bi
R
i
t
of ze a
M rla
ac nd
ed
on
Tu ia
rk
ey
Ic
Fi
nl
a
S w nd
ed
E s en
to
ni
La a
Li t via
th
ua
Cr ni a
oa
t
Ir e i a
la
n
Po d
l
Sl and
N e ove
t h ni
er a
la
De nd
nm s
ar
k
Lu Fr a
xe n c
m e
bo
ur
g
EU
Au 28
st
Be ria
lg
Un G ium
i t e er m
d
K i any
ng
do
m
M
al
ta
It a
Sl
ly
ov
a k Sp
C z Re a in
e c pu
h
Re b l i c
pu
b
Bu lic
lg
Ro a r i a
m
a
Po ni a
r tu
Hu g a
ng l
a
Gr r y
ee
c
Cy e
pr
us
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en, WHO Europe Health for All Database.
1 2 http://dx.doi.org/10.1787/888933155424
1.9.2. Trends in low birth weight infants, selected European countries, 1980-2012
Finland
Greece
Poland
Portugal
Spain
EU28
% of newborns weighing less than 2 500 g

10
2
1980
1985
1990
1995
2000
2005
2010
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en, WHO Europe Health for All Database.
1 2 http://dx.doi.org/10.1787/888933155424
33
1.10. SELF-REPORTED HEALTH AND DISABILITY
The health module in the EU Statistics on Income and

Living Conditions survey (EU-SILC) allows respondents to
report on their general health status, whether they have a
chronic illness and whether they are limited in usual
activities because of a health problem. Despite the
subjective nature of these questions, indicators of
perceived general health have been found to be a good
predictor of peoples future health care use and mortality
(DeSalvo et al., 2005; Bond et al., 2006).
For the purpose of international comparisons, crosscountry differences in perceived health status can be
difficult to interpret because responses may be affected by
social and cultural factors. Since they rely on the subjective
views of respondents, self-reported health status may
reflect cultural biases or other influences. Also, since older
people report poor health more often than younger people,
countries with a larger proportion of elderly people will also
have a lower proportion of people reporting good or very
good health.
With these limitations in mind, adults in the European
Union are generally rating their health quite positively: only
11% on average reported to be in bad or very bad health
in 2012 (Figure 1.10.1). Ireland and Sweden, as well as
Switzerland have the highest proportion of adults rating their
health as good or very good, with more than 80% doing so. By
contrast, less than 50% of adults in Lithuania, Croatia, Latvia
and Portugal reported to be in good or very good health.
In all European countries, men are more likely than
women to rate their health as good, with the largest gender
gap in Portugal and the Slovak Republic. As expected,
peoples rating of their own health tends to decline with
age. In many countries, there is a particularly marked
decline in a positive rating of ones own health after age 45
and a further decline after age 65. People with a lower level
of education or income also do not rate their health as
positively as people with higher levels (OECD, 2014).
EU-SILC also asks whether respondents had any longstanding illnesses or health problems. Three-in-ten adults
in EU member states reported having such chronic illnesses
or health problems in 2012 (Figure 1.10.2). Adults in Finland
and Estonia were more likely to report having some longstanding illnesses or health problems, while these
conditions were less commonly reported in Romania and
Bulgaria. Women reported some long-standing illnesses or
health problems more often than men (an average of 34%
versus 29% across EU member states), with the gender gap
greatest in Finland and Latvia. As expected, reporting of
chronic illnesses also increases with age, from an average of
7% of young people aged 16-24 years, to 61% among people
aged 65 years and over.
commonly reported such activity limitations in Finland,

Germany, Slovenia, the Slovak Republic and Estonia (30% or
more of respondents), and less so in Malta, Sweden and
Norway (less than 16%).
Adults with activity limitations were more likely to
report some long-standing illnesses (R = 0.28). There was,
however, a moderate association between adults reporting
to be in bad health and those reporting activity limitations
(R = 0.16). Those countries with the lowest rates of adults
reporting to be in bad health also had the lowest rates of
adults reporting limitations in usual activities (e.g. Ireland,
Sweden and Malta), while those reporting the highest rates
of adults in bad health were not necessarily those reporting
the highest rates of adults with activity limitations
(e.g. Croatia and Lithuania).

The three questions used in the EU-SILC survey to
measure health and the prevalence of chronic
illnesses and disability 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
6 months or more?, and iii) For at least the past
6 months, to what extent have you been limited
because of a health problem in activities people
usually do? Would you say you have been severely
limited, limited but not severely, or not limited at all?.
Persons in institutions are not surveyed. Caution is
required in making cross-country comparisons of
perceived general health, since peoples assessment
of their health is subjective and can be affected by
their social and cultural backgrounds.
References
Bond, J. et al. (2006), Self-rated Health Status as a Predictor
of Death, Functional and Cognitive Impairments: A Longitudinal Cohort Study, European Journal of Ageing,
Vol. 3, pp. 193-206.
DeSalvo, K.B. et al. (2005), Predicting Mortality and Healthcare Utilization with a Single Question, Health Services
Research, Vol. 40, pp. 1234-1246.
OECD (2014), OECD Health Statistics 2014, online, OECD
Publishing, Paris, www.oecd.org/health/healthdata.
When adults were asked whether they were limited in

usual daily activities because of a health problem which is
one definition of disability one-quarter on average across
EU member states answered that they were, with 7.6% of
respondents reporting to be severely limited and 17.3%
limited to some extent (Figure 1.10.3). Adults most
34
al
35
82
47
% of the population aged 16 years and over

50
34.0
30.8
27
15
5.8
21
10.2
28.8
26
Ic
el
a
No nd
Sw r w
i t z ay
er
la
nd
48
46.7
38
7.1
45
43.7
15
13.2
27.1
37.1
48
10.9
52
11.5
60
23.2
20
34
22.0
31
18
6.8
30
16
37.0
58
10.0
26
23.2
58
16
36.6
60
28
36.0
63
15
9.8
27
9.3
Fair
22.8
24
20.3
70
35.3
13
9.5
35.2
12
19.8
6.9
Limited to some extent
21.9
65
34.6
26
5.8
40
9
22.3
66
34.5
66
22
6.8
23
13
20.8
67
11
34.0
22
33.1
67
12
9.2 4.3
8.2
17.7
68
26
32.9
23
9.6
8.0
17.5
68
32.6
12
17.6
7.9
17.5
19
31.1
70
8.8
30
16.3
21
30.0
29.8
7.6
70
6.2
20
17.5
35
10
17.3
71
29.6
22
7.5
74
16.1
23
29.4
28.9
5.3
74
10.1
19
17.8
74
12.6
17
28.9
5.1
74
26.5
26.2
24.5
18
16.7
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76
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23.8
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1.10. SELF-REPORTED HEALTH AND DISABILITY
1.10.1. Self-reported health status, 2012

Bad or very bad
50
6
5
15
18
79
77
44
10
Source: EU-Statistics on Income and Living Conditions survey.
1 2 http://dx.doi.org/10.1787/888933155435
1.10.2. Self-reported long-standing illness or health problem, 2012
15
10
1 2 http://dx.doi.org/10.1787/888933155435
1.10.3. Self-reported limitation in usual activities, 2012

40
Limited severely
1 2 http://dx.doi.org/10.1787/888933155435
35
1.11. INCIDENCE OF SELECTED COMMUNICABLE DISEASES
Communicable diseases such as measles, pertussis and

hepatitis B still pose major threats to the health of
European citizens. Measles, a highly infectious disease of
the respiratory system, is caused by a virus. Symptoms
include fever, cough, runny nose, red eyes and skin rash. It
can lead to severe health complications, including
pneumonia, encephalitis, diarrhoea and blindness.
Pertussis (or whooping cough) is highly infectious, and is
caused by a bacteria. 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 measles, pertussis and hepatitis B is available
through vaccination (see Ind icat or 4.9, Childhood
vaccination programmes).
A total of 13 797 confirmed measles cases were reported
in the European Union in 2011, with an overall rate of
6.4 cases per 100 000 population, almost unchanged
compared to 2010. Twenty countries reported rates below
one case per 100 000 population which is the target for the
elimination of the disease (Figure 1.11.1). France was the
most affected country with a notification rate of 23 cases
per 100 000 population in 2011. Several other countries
reported outbreaks, including Romania, Italy, Spain,
Belgium and Ireland. The most affected age group were
children aged 0-4 year-olds, followed by 5-14 year-olds.
Most infections occurred in late winter and early spring
(ECDC, 2013). In September 2010, all European countries
re n ewe d t h e i r c o m m it m e n t t o t h e e l i m i n a t i o n o f
indigenous transmission of measles by 2015. To achieve this
goal, all efforts must be directed towards reaching a
vaccination coverage of at least 95%, with at least one dose
of measles-containing vaccine. This dose is generally
administrated to children around the age of one year with a
second dose before starting school (4/5 years old). In France,
the estimated percentage of children aged around 1 year
old who had received the first dose was only 89% in 2011,
and this proportion remained unchanged in 2012 (see
Figure 4.9.2 in Chapter 4).
In 2011, 12 529 confirmed pertussis cases were reported
in EU member states. The overall incidence rate was 4.4 per
100 000 population, an increase of 25% compared with 2010,
but comparable with the rates observed in previous years.
Within EU countries, the highest incidence rates were
reported in Estonia (36 cases per 100 000 population), the
Netherlands (33 cases), the Slovak Republic (17 cases) and
Slovenia (14 cases) (Figure 1.11.2). But the incidence rate
was much greater in Norway, due to more extensive testing.
Young children and adolescents were the most affected age
groups, although increases were seen across all age groups
(ECDC, 2013). Pertussis is no longer solely a paediatric
36
infection and immunisation that is given at around one

year of age as part of national childhood immunisation
programmes does not confer lifelong immunity. ECDC
recommends that vaccine strategies should be revisited
and boosters given to adolescents and adults, to provide
greater protection. Some countries have already added an
adolescent pertussis booster vaccine to their vaccination
schedule (e.g., Austria, Belgium, Finland, France, Germany
and Italy).
A total of 16 488 hepatitis B cases were reported in EU
member states in 2011, a rate of 3.4 per 100 000 population.
Sweden, the United Kingdom, Latvia and Ireland had the
highest incidence rates among EU countries, with more than
ten cases per 100 000 population (Figure 1.11.3). The
incidence rate was even higher in Norway, due to more
extensive testing (including the testing of all immigrants
coming from countries with high number of cases). The
incidence of hepatitis B is higher in men than in women.
Around one third of all reported hepatitis B cases occurs
among people aged 25-34. Heterosexual transmission is the
most common route of transmission, followed by nosocomial
transmission for acute cases, while mother-to-child
transmission was the most common route for chronic cases.

Mandatory notification systems for communicable
diseases, including measles, pertussis and hepatitis B,
exist in most European countries, although case
definitions, laboratory confirmation requirements
and reporting systems may differ. Measles, hepatitis B
and pertussis notification is mandatory in all
EU member states, but only the data collected by the
sentinel surveillance system in France and Belgium is
reported at the international level.
Caution is required in interpreting the data because
of the diversity in surveillance systems, case
definitions and reporting practices (for example,
several countries only collect data on acute cases, not
chronic cases). Variation between countries also likely
reflects differences in testing as well as differences in
immunisation and screening programmes (ECDC,
2013).
References
ECDC (2013), Annual Epidemiological Report 2013. Reporting on
2011 Surveillance Data and 2012 Epidemic Intelligence Data,
ECDC, Stockholm.
1.11. INCIDENCE OF SELECTED COMMUNICABLE DISEASES
1.11.1. Notification rate of measles, 2011
1.11.2. Notification rate of pertussis, 2011
Cyprus
Portugal
Slovak Republic
Latvia
Hungary
Poland
Czech Republic
Lithuania
Sweden
Netherlands
Greece
Finland
Estonia
Malta
Slovenia
Luxembourg
Austria
Denmark
United Kingdom
Germany
Bulgaria
Ireland
Belgium
Spain
Italy
Romania
France
Greece
Hungary
Cyprus
Portugal
Romania
Latvia
Italy
Bulgaria
Luxembourg
Lithuania
Sweden
United Kingdom
Iceland
Norway
0
0
0
0
Czech Republic
Austria
Poland
Ireland
Spain
Malta
Denmark
1
1
1
Finland
Slovenia
8
6
8
10
14
Slovak Republic
9
17
Netherlands
19
33
Estonia
23
36
Iceland
Norway
10
20
30
Per 100 000 population
0
90
Source: ECDC (2013), Annual Epidemiological Report 2013.

1 2 http://dx.doi.org/10.1787/888933155445
50
100

1 2 http://dx.doi.org/10.1787/888933155445
1.11.3. Notification rate of hepatitis B, 2011

18
16
16
14
14
14
13
12
12
10
10
10
8
8
6
5
ay
d
an
rw
el
No
Ic
en
Un
i te
Sw
ed
ia
do
tv
La
ng
Ki
nd
nd
la
Ir e
ria
la
st
er
Ne
th
Au
ta
ar
al
M
nm
De
ia
an
nl
Fi
ia
ar
Bu
lg
en
ni
to
ov
Es
bl
pu
Re
Sl
ic
ia
ur
Sl
ov
xe
bo
an
m
Ro
Lu
ak
ic
ni
bl
ua
pu
th
Re
h
ec
Cz
Li
us
pr
ai
Sp
ly
an
rm
Ge
nd
ar
la
ng
Hu
It a
Po
ce
Gr
ga
ce
an
r tu
Po
Fr
ee
Cy
1 2 http://dx.doi.org/10.1787/888933155445
37
1.12. HIV/AIDS
The onset of AID S is caused by HIV (hum an

immunodeficiency virus) infection and can manifest itself
through many different diseases, such as pneumonia and
tuberculosis, as the immune system is no longer able to
defend the body, leaving it susceptible to different
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 or vaccine
currently available. HIV remains a major public health issue
in Europe, with approximately 800 000 people living with
HIV infection in the European Union in 2012 and continued
transmission increasing this number.
In 2012, more than 29 000 cases of newly-diagnosed HIV
infection were reported in EU member states. Estonia had
the highest rate of new cases (23.5 per 100 000 population),
followed by Latvia, Belg ium, Luxemb ourg and the
United Kingdom. Since 2000, the main transmission route
in Estonia has been the sharing of contaminated needles
among drug users, along with increases in sexual
transmission (WHO Regional Office for Europe, 2011). The
lowest rates were in the Slovak Republic, Croatia and the
C z e ch R ep u bl i c ( Fi g u re 1 .1 2 .1 ) . O n ave rag e a c ro s s
EU member states, 6.3 new cases of HIV infection were
diagnosed per 100 000 population in 2012. More than twothirds of these cases were among men. The predominant
mode of transmission of HIV was through men having sex
with men (40%), followed by heterosexual contact (34%). In
certain countries, drug use through injections is also a
common mode.
The rate of newly-diagnosed HIV cases has been fairly
stable on average in EU countries over the past decade, but
this hides diverging trends across countries. Between 2002
and 2012, the rate of newly-diagnosed HIV has more than
doubled in Greece and is now well above the EU average.
This is partly due to the dramatic rise in the number of new
HIV cases among injecting drug users in Athens since 2010,
following reduction in funding for opioid substitution and
needle exchange programmes in previous years. On the
other hand, the rates have dropped sharply in Estonia and
Portugal, although they remain above the EU average
(Figure 1.12.2). Trends by transmission mode show that the
number of HIV diagnoses among homosexual males has
increased by around 11% since 2006. By contrast, the
number of cases among drug users has decreased by
around 7%. The numbers of H IV diagnoses due to
heterosexual transmission, mother-to-child transmission
and blood transfusion have also decreased between 2006
and 2012 (ECDC and WHO Regional Office for Europe, 2013).
The number of newly-reported cases of AIDS in
EU member states in 2012 was 4 287, representing an
average incidence rate of 1.1 per 100 000 population
(Figure 1.12.1; right panel). Following the first reporting of
AIDS in the early 1980s, the number of cases rose rapidly to
r e a c h a n av e r a g e o f a l m o s t f o u r n ew c a s e s p e r
100 000 population across EU member states at its peak in
the middle of the 1990s. Public awareness campaigns
contributed to steady declines in new cases of HIV/AIDS in
38
the second half of the 1990s. The development and greater

availability of antiretroviral drugs, which reduce or slow
down the development of the disease, also led to a sharp
decrease in incidence since the mid-1990s.
Latvia had the highest AIDS incidence rates among
EU member states in 2012, followed by Estonia, Portugal
and Spain (Figure 1.12.1). While Spain had the highest
incidence rate in the first decade following the outbreak,
the rate has declined sharply since the mid-1990s. The
incidence rate in Portugal peaked somewhat later, towards
the end of the 1990s, but has also declined sharply since
then. In Latvia, the number of newly-reported cases of AIDS
has co ntinued to increase rapidly in recent years
(Figure 1.12.3). The low rates in some countries may be due
to incomplete reporting (ECDC and WHO Regional Office for
Europe, 2013).
While the number of new AIDS cases has decreased in
most EU countries, continued transmission of HIV and the
rising number of newly-diagnosed cases in some countries
calls for effective interventions to prevent the spread of this
virus. There is a need to reduce new HIV infections across
all European countries through effective prevention, and to
improve access to treatment for people infected (ECDC and
WHO Regional Office for Europe, 2013).

The incidence rates of HIV (human
immun o deficiency virus) an d AIDS (ac q uired
immunodeficiency syndrome) are the number of new
cases per 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. Under-reporting
and under-diagnosis also affect incidence rates, and
could represent as much as 40% of cases in some
countries (ECDC and WHO Regional Office for Europe,
2013). Note that data for recent years are provisional
due to reporting delays, which can sometimes be for
several years.
References
ECDC and WHO Regional Office for Europe (2013), HIV/AIDS
Surveillance in Europe 2012, ECDC, Stockholm.
WHO Regional Office for Europe (2011), HIV Epidemic in
Estonia: Analysis of Strategic Information, WHO Europe,
Copenhagen.
1.12. HIV/AIDS
1.12.1. HIV and AIDS incidence rates in 2012

HIV incidence
AIDS incidence
Slovak Republic
Croatia
Czech Republic
Bulgaria
Hungary
Slovenia
Romania
Poland
Finland
Denmark
Germany
Austria
Sweden
Lithuania
Netherlands
France
EU28
Italy
Cyprus
Portugal
Malta
Ireland
Spain
Greece
United Kingdom
Luxembourg
Belgium
Latvia
Estonia
0.9
1.7
2.0
2.1
2.2
2.2
2.3
2.8
2.9
3.6
3.6
3.6
3.8
5.3
5.8
6.2
6.3
6.4
6.7
7.0
7.2
7.4
8.5
9.4
10.3
10.3
11.1
16.6
23.5
4.9
5.9
8.1
20
15
0.6
0.3
0.9
0.5
0.5
1.4
0.4
0.4
0.7
0.3
0.3
0.7
1.3
1.2
0.8
1.1
1.2
0.6
2.4
1.4
0.7
1.7
1.0
0.6
1.3
0.7
6.8
2.7
FYR of Macedonia
Turkey
Serbia
Montenegro
Norway
Iceland
Switzerland
0.7
1.4
1.7
2.1
25
0.1
10
5
0
New cases per 100 000 population
0.4
0.1
0.7
1.1
0.5
0.3
0.7
6
8
Source: ECDC and WHO Regional Office for Europe (2013), HIV/AIDS Surveillance in Europe 2012.
1 2 http://dx.doi.org/10.1787/888933155453
1.12.2. Trends in HIV incidence rates, selected EU member

states, 2002-12
Estonia
France
Portugal
EU28
1.12.3. Trends in AIDS incidence rates, selected

EU member states, 2002-12
Greece

70
Estonia
Latvia
Spain
EU28
Portugal

12
60
10
50
8
40
6
30
4
20
2
10
0
2002
2004
2006
2008
2010
2012
Source: ECDC and WHO Regional Office for Europe (2013), HIV/AIDS
Surveillance in Europe 2012.
1 2 http://dx.doi.org/10.1787/888933155453
0
2002
2004
2006
2008
2010
2012
Source: ECDC and WHO Regional Office for Europe (2013), HIV/AIDS
Surveillance in Europe 2012.
1 2 http://dx.doi.org/10.1787/888933155453
39
1.13. CANCER INCIDENCE
In 2012, an estimated 2.7 million new cases of cancer

were diagnosed in EU member states, 54% (around
1.5 million) occurring in men and 46% (around 1.2 million)
in women. The most common cancer site was breast cancer
(13.8% of all new cancer cases), followed by prostate cancer
(13.6%), colorectal cancer (13%) and lung cancer (11.8%).
These four cancers represented more than half of the
estimated overall burden of cancer in the European Union
(Ferlay et al., 2013). The risk of getting cancer before the age
of 75 years was 27% (31% for men and 24% for women) and
the risk of dying from cancer also before the age of 75 was
12% (14% for men and 9% for women).
Large variations exist in cancer incidence across
European countries. Cancer incidence is highest in
northern and western European countries, with Denmark,
France, Belgium and Norway registering more than 300 new
cancer cases per 100 000 population in 2012 (Figure 1.13.1).
The lowest rates were reported in some Mediterranean
countries such as Greece, Cyprus, and Turkey, at around
200 new cases per 100 000 population. These variations
reflect not only variations in the prevalence of risk factors
for cancer, but also national policies regarding cancer
screening and differences in quality of reporting.
Cancer incidence rates were higher for men in all
EU member states in 2012, although the gender gap varies
widely across countries. In Turkey, Estonia, Spain and
Latvia, incidence rates among men were around 60% higher
than among women, whereas in the United Kingdom,
Denmark, Iceland and Cyprus, the gap was less than 10%.
Breast was by far the most common primary sites in
women (30% on average), followed by colorectal (13%), lung
(8%), and cervical (5%). The causes of breast cancer are not
fully understood, but the risk factors include age, family
history, breast density, exposure to oestrogen, being
overweight or obese, alcohol, radiation and hormone
replacement therapy. Incidence rates were highest in
western Europe (Belgium, France, the Netherlands and
Germany), Denmark, the United Kingdom and Ireland, with
rates 25% or more than the EU average (Figure 1.13.2).
Greece had the lowest rate, followed by Baltic countries
(Lithuania, Estonia and Latvia), Romania and Poland. The
variation in breast cancer incidence across EU member
states may be at least partly attributed to variation in the
extent and type of screening activities (Ferlay et al., 2013).
Although mortality rates for breast cancer have declined in
most EU countries since the 1990s due to earlier detection
and improvements in treatments, breast cancer continues
to be the leading cause of death from cancer among
women (see Indicator 1.5 Mortality from cancer and 4.7
Screening, survival and mortality from breast cancer).
obesity, lack of exercise and nutrition habits are the main

risk factors. Incidence rates were highest in western
European countries such as France, Ireland and Switzerland
as well as in the Nordic countries (Sweden, Norway, Iceland
and Finland) (Figure 1.13.3). Greece had the lowest rates,
followed by central and eastern European countries
(Bulgaria, Romania, Poland and Hungary). Prostate
incidence rates have increased in most European countries
since the late 1990s, particularly in northern and western
Europe where the greater use of prostate specific antigen
(PSA) tests led to greater detection. Part of the difference
between countries can be attributed to difference in the use
of PSA testing. Mortality rates from prostate cancer have
decreased in some European countries as a consequence of
early detection and improvements in treatments.

Cancer incidence rates are based on numbers of
new cases of cancer registered in a country in a year
divided by the population. The rates have been
directly age-standardised based on Segis world
population to remove variations arising from
differences in age structures across countries and
over time. The data come from the International
Agency for Research on Cancer (IARC), GLOBOCAN
2012, available at globocan.iarc.fr. GLOBOCAN
estimates for 2012 may differ from national estimates
due to differences in methods.
Cancer registration is well established in most EU
member states, although the quality and
completeness of cancer registry data may vary. In
s o m e c o u n t r i e s , c a n c e r reg i s t ri e s o n ly c ove r
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). Breast cancer corresponds to C50, and
prostate cancer to C61.
References
Ferlay, J. et al. (2013), Cancer Incidence and Mortality Patterns in Europe: Estimates for 40 Countries in 2012,
European Journal of Cancer, Vol. 49, pp. 1374-1403.
Prostate cancer has become the most commonly

diagnosed cancer among men in almost all EU countries,
except in some central and eastern European countries
where lung cancer is still predominant. It accounted for one
quarter (25%) of all new cancer diagnoses in men in 2012,
followed by lung (15%), colorectal (13%) and bladder cancer
(7%). As for breast cancer, the causes of prostate cancer are
not well-understood but age, ethnic origin, family history,
40
1.13. CANCER INCIDENCE
1.13.1. All cancers incidence rates, men and women, 2012

Men
Women
Total

400
350
300
250
200
150
100
50
M Tur
on k
of ten ey
M eg
ac ro
ed
on
Se ia
rb
I ia
S w c el
i t z and
er
la
No nd
rw
ay
R
FY
Gr
ee
C y ce
p
Ro r u s
m
an
Po i a
la
Bu nd
lg
a
Es ria
to
ni
a
M
Po al t a
r tu
ga
La l
tv
ia
S
L i p a in
th
ua
n
Au ia
st
r
Fi ia
nl
an
d
EU
28
Cr
oa
Un
t
i te S w ia
Sl d K ede
ov in n
a k gd
Re om
pu
bl
ic
Lu
xe I t a
m ly
bo
G e ur g
rm
C z H any
e c un
h ga
Re r y
pu
S blic
N e love
t h ni
er a
la
nd
Ir e s
la
B e nd
lg
iu
Fr m
an
De ce
nm
ar
k
Source: International Agency for Research on Cancer (IARC), GLOBOCAN 2012.
1 2 http://dx.doi.org/10.1787/888933155469
1.13.2. Breast cancer incidence rates, women, 2012
1.13.3. Prostate cancer incidence rates, men, 2012
Greece
Lithuania
Romania
Estonia
Poland
Latvia
Hungary
Slovak Republic
Bulgaria
Croatia
Slovenia
Spain
Portugal
Austria
Czech Republic
EU28
Cyprus
Sweden
Malta
Luxembourg
Finland
Italy
Germany
Ireland
United Kingdom
Netherlands
France
Denmark
Belgium
Greece
Bulgaria
Romania
Poland
Hungary
Croatia
Slovak Republic
Malta
Cyprus
Lithuania
Portugal
Spain
Italy
EU28
Czech Republic
United Kingdom
Austria
Germany
Luxembourg
Latvia
Slovenia
Netherlands
Belgium
Denmark
Estonia
Finland
Ireland
Sweden
France
44
49
50
52
52
52
55
58
59
61
67
67
68
68
70
74
78
80
86
89
89
91
92
92
95
99
105
105
112
Turkey
Montenegro
Serbia
Norway
FYR of Macedonia
Switzerland
Iceland
39
60
69
73
76
83
96
25
50
75
100
150
125
Age-standardised rates per 100 000 females
Source: International Ag en cy for Research on Cancer (IARC),

GLOBOCAN 2012.
1 2 http://dx.doi.org/10.1787/888933155469
20
24
24
36
38
46
50
51
55
61
64
65
68
70
72
73
75
77
79
83
83
83
91
91
94
97
114
119
127
FYR of Macedonia
Montenegro
Serbia
Turkey
Iceland
Switzerland
Norway
28
34
37
41
107
107
130
25
50
75
100
150
125
Age-standardised rates per 100 000 males
Source: In ternational A g en cy for R esearch on Canc er (IARC),

GLOBOCAN 2012.
1 2 http://dx.doi.org/10.1787/888933155469
41
1.14. DIABETES PREVALENCE AND INCIDENCE
Diabetes is a chronic 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 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.
In 2013, an estimated 32 million adults aged 20-79 years
old had diabetes in the European Union, according to the
International Diabetes Federation. This represents 6% of
the population in this age group (IDF, 2013). If left
unchecked, the number of people with diabetes in EU
member states is projected to reach around 38 million by
2035. Portugal, Cyprus, Germany and Spain had the highest
estimated prevalence of diabetes in 2013, with over 8% of
the population in this age group (Figure 1.14.1).
Type-1 diabetes accounts for only 10-15% of all diabetes
cases. However, it is the predominant form of the disease in
younger age groups in European countries. Based on
disease registers and recent studies, the annual number of
new cases of type-1 diabetes in children aged under 15 was
highest in 2013 in Nordic countries (Finland, Sweden and,
to a lesser extent, in Denmark and Norway) (Figure 1.14.2)
and in the United Kingdom. Alarmingly, there is evidence in
several countries that type-1 diabetes is developing at an
earlier age.
In 2013, around 271 300 people were estimated to have
died from diabetes-related diseases, making diabetes the
4th leading cause of death in Europe. However, only a
minority of persons with diabetes die from diseases
uniquely related to the condition. Of all people with
diabetes, 50% die of cardiovascular disease and another
10-20% die of kidney failure (IDF, 2013).
The economic burden of diabetes is also substantial.
Health expenditure in EU member states allocated to
prevent and treat diabetes and its complications was
estimated to be in the order of EUR 100 billions in 2013 (IDF,
2013). Over one-quarter of these health 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. The
growing costs related to diabetes reinforce the need for
42
effective preventive actions and the provision of quality

care to manage effectively diabetes and its complications.
In March 2014, the European Diabetes Leadership Forum
brought together a wide range of stakeholders to discuss
good practice on secondary prevention of diabetes in
Europe, as well as greater patient empowerment in diabetes
management (European Diabetes Leadership Forum, 2014).
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 associated with diabetes. But in most
countries, the prevalence of overweight and obesity
continues to increase (see Indicator 2.5 Overweight and
obesity among adults).

The sources and methods used by the International
Diab etes Federation to estimate the national
prevalence of diabetes are outlined in the Diabetes
Atlas, 6th edition (IDF, 2013; Guariguata et al., 2013).
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 other sources
with available data.
Prevalence rates were adjusted to the World
S t a n d a rd Po p u l a t i o n t o re m ove t h e e f f e c t o f
differences in population structures across countries.
References
European Diabetes Leadership Forum (2014), European Diabetes Leadership Forum, available at: diabetesleadershipforum.eu.
Guariguata, L. et al. (2013), Global Estimates of Diabetes
Prevalence for 2013 and Projections for 2035, Diabetes
Research and Clinical Practice, Vol. 103, No. 2, pp. 137-149.
IDF (2013), Diabetes Atlas, 6th edition, International Diabetes
Federation, Brussels.
oa
20
57.6
Cases per 100 000 population

60
32.8
50
43.2
la
nd
Ic
el
an
No d
Sw r w
i t z ay
er
la
nd
3.2
4.7
5.9
6.9
6.6
6.6
6.3
6.0
6.0
5.8
5.7
5.6
5.5
5.4
5.3
5.2
5.2
5.1
8.3
8.2
7.9
7.5
9.6
9.3
%
10
14.7
13.1
30
28.2
Po
4.9
25.1
21.9
th
ly
er
la
n
Bu ds
lg
ar
i
Fr a
an
c
Ir e e
la
nd
Cr
oa
t
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to
ni
Fi a
nl
an
d
EU
Hu 2 8
ng
De ar y
nm
ar
Au k
st
ria
Cz
ec M
al
h
Re t a
pu
bl
i
Sl
ov Slov c
ak
en
Re i a
pu
bl
ic
Sp
Ge a in
rm
an
Cy y
pr
Po us
r tu
ga
l
Ne
It a
4.8
4.8
4.7
4.6
4.6
4.0
3.9
21.9
20.6
19.3
19.0
ia
ia
ur
tv
bo
La
18.6
18.4
18.2
17.5
17.3
17.1
16.3
15.9
14.6
14.4
14.2
xe
ni
an
Sw
ed
B e en
lg
iu
m
Un
i t e Gr e
d
e
Ki ce
ng
do
m
Lu
13.6
13.2
12.2
12.1
10.4
9.4
9.1
7.5
5.4
ua
th
Ro
Li
Bu t i a
lg
ar
i
Gr a
ee
ce
It a
l
Fr y
an
Sl
P c
ov or e
ak tug
Re a l
pu
Li blic
th
ua
ni
Cy a
pr
Sl us
ov
en
Be ia
lg
iu
m
Ir e
la
nd
Es
to
ni
Po a
la
n
Au d
st
Hu r i a
ng
ar
y
Ne EU
th 28
e
Lu rla
n
x
C z em d s
ec bo
u
h
Re r g
pu
bl
ic
Sp
a
Ge in
rm
an
y
M
a
Un D e l t a
i t e nm
d
K i ar k
ng
do
Sw m
ed
e
Fi n
nl
an
d
Sw
it z
er
la
n
Ic d
el
an
No d
rw
ay
Cr
ia
ia
10
tv
an
La
Ro
1.14. DIABETES PREVALENCE AND INCIDENCE
1.14.1. Prevalence estimates of diabetes, adults aged 20-79 years, 2013
Note: The data are age-standardised to the World Standard Population.

Source: IDF (2013), Diabetes Atlas, 6th edition.
1 2 http://dx.doi.org/10.1787/888933155471
1.14.2. Incidence estimates of type-1 diabetes, children aged 0-14 years, 2013
40
Source: IDF (2013), Diabetes Atlas, 6th edition.
1 2 http://dx.doi.org/10.1787/888933155471
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 individuals 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. Alzheimers 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 slow the progression of
the disease.
such as France, the United Kingdom and Germany have

dementia strategy plans or created special benefits for
dementia (OECD, 2013). National policies typically involve
measures to encourage diagnosis without stigma, promote
quality of care for people with dementia, and support
informal caregivers (OECD, forthcoming). The World
Dementia Council was formed following the UK-led G8
summit on Dementia in December 2013, with the objective
to promote innovation and development of life-enhancing
drugs, treatments and care for people with dementia.
In 2012, an estimated 8.4 million people aged 60 years

and over were suffering from dementia in EU member
states, accounting for 7% of the population in that age
group, according to estimates of Alzheimer Europe
(Figure 1.15.1). Italy, Spain and France had the highest
prevalence rates, with more than 7.5% of the population
aged 60 years or older.
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 to suffer from dementia in 2012, compared
to less than 4% among those under 75 years of age
(Alzheimer Europe, 2013). Among people aged 90 years and
over, the figures rise to 30% of men and 47% of women.
Early-onset dementia among people aged younger than
65 years is rare; they comprise less than 1% of the total
number of people with dementia.
The direct costs of dementia account for a significant
share of total health expenditure in European countries,
greater than the direct costs related to depression and other
mental disorders such as schizophrenia (Figure 1.15.3). In
the Netherlands, dementia accounted for nearly 5.5% of
overall health spending in 2011, with this share slightly
rising over time. Most of these costs were related to caring
for people with dementia in nursing homes, but part of the
costs was also related to home-based care and a smaller
proportion for hospital-based care. In Germany, dementia
accounted for 3.7% of total health expenditure in 2008,
slightly up from 3.5% in 2004, with most of the costs also
allocated for care in nursing homes.
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. Given the divergence in
scale and accuracy of the sources used across
countries, the estimates should be used with caution.
References
Alzheimer Europe (2013), Dementia in Europe Yearbook 2013,
www.alzheimer-europe.org/Publications/Dementia-inEurope-Yearbooks.
European Commission (2014), Implementation Report on
the Commission Communication on a European Initiative on Alzheimers Disease and Other Dementias,
Commission Staff Working Document, SWD(2014)321
final, Brussels.
OECD (2013), Addressing Dementia: The OECD Response, OECD
Publishing, Paris, www.oecd.org/sti/addressing-dementiathe-oecd-response.pdf.
OECD (forthcoming), Dignity in Dementia, OECD Publishing,
Paris.
The European Commission launched in 2009 a European

Initiative on Alzheimers disease and other dementias
(European Commission, 2014). Several EU member states
44
1.15. DEMENTIA PREVALENCE
7.1
7.1
6.6
7.7
7.5
7.5
7.1
7.1
7.0
7.0
7.0
6.9
6.9
6.9
6.8
6.7
6.7
6.5
6.5
6.4
6.3
6.3
6.2
6.2
6.2
5.7
5.6
5.5
5.1
5.5
6.2
%
8
7.2
1.15.1. Prevalence of dementia, population aged 60 years and over, 2012
3.7
5
4
3
2
1
y
a
No nd
Sw r w
i t z ay
er
la
nd
ke
el
Tu
r
Ic
Sl
ov
ak
Re
M
al
ta
pu
bl
C z Bu ic
ec lg
a
h
Re r i a
pu
Ro b l i c
m
a
Hu ni a
ng
ar
Po y
la
n
Ir e d
la
nd
C
Ne roa
th tia
er
la
De nds
nm
L i ar k
th
ua
Sl ni a
ov
en
Fi ia
nl
an
E d
Lu s to
xe ni
m a
bo
ur
Cy g
pr
Po us
r tu
ga
La l
tv
i
Gr a
ee
ce
Un
i te
d EU2
Ki
ng 8
d
Ge om
rm
a
Sw ny
ed
e
Au n
st
r
Be ia
lg
iu
m
Fr
an
ce
Sp
ai
n
It a
ly
Source: Alzheimer Europe (2013), Prevalence of Dementia in Europe.
1 2 http://dx.doi.org/10.1787/888933155486
1.15.2. Age- and sex-specific prevalence of dementia in EU member states, 2012

Women
Men
Prevalence (%)
60
50
40
30
20
10
0
60-64
65-69
70-74
75-79
80-84
85-89
90+
Age group
Source: Alzheimer Europe (2013), Prevalence of Dementia in Europe.
1 2 http://dx.doi.org/10.1787/888933155486
1.15.3. Trends in share of health expenditure allocated to dementia and other mental disorders, Germany
and the Netherlands
Dementia
Schizophrenia
Depression
% of total health expenditure

6
5
4
3
2
1
0
2004
2006
Germany
2008
2005
2007
Netherlands
2011
Source: OECD Expenditure by Disease, Age and Gender, 2014.
1 2 http://dx.doi.org/10.1787/888933155486
45

OECD 2014
Chapter 2
Determinants of health
2.1. Smoking among adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
2.2. Alcohol consumption among adults . . . . . . . . . . . . . . . . . . . . . . . . . . .
50
2.3. Use of illicit drugs among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
52
2.4. Fruit and vegetable consumption among adults . . . . . . . . . . . . . . . . .
54
2.5. Overweight and obesity among adults. . . . . . . . . . . . . . . . . . . . . . . . . .
56
2.6. Air pollution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58
47
2.1. SMOKING AMONG ADULTS
To bacco kills nearly 6 million p eople each year

worldwide, of whom more than 5 million are from direct
tobacco use and more than 600 000 are non-smokers
exposed to second-hand smoke (WHO, 2014). 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 is also 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 adults varies
greatly across European countries (Figure 2.1.1). One-third
of EU countries had less than 20% of the adult population
smoking daily in 2012. Rates were lowest in Nordic
countries (Sweden, Denmark, Finland, as well as in Iceland
and Norway), followed by Luxembourg, the Netherlands
and Portugal. Although large disparities remain, smoking
rates across most EU member states have shown a marked
decline. On average, smoking rates have decreased by 12%
since 2002, with a higher decline among men than women.
Large declines occurred in Denmark (28% to 17% in 2013),
Luxembourg (26% to 17% in 2012), the Netherlands (28% to
18% in 2012) as well as in Norway (29% to 16% in 2012) and
in Iceland (21% to 14% in 2012). Greece, Croatia and Bulgaria
had the highest level of smoking around 2012, with 30% to
40% of adults reporting to smoking daily respectively.
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 (European
Commission, 2014a). In addition to government policies,
actions by anti-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 than women
in all European countries, except in Sweden and Norway
where the rate is equal for men and women (Figure 2.1.2).
The gender gap is also small in other Nordic countries
(Denmark and Iceland), and in Luxembourg and the
48
United Kingdom. On the other hand, it is particularly large

in Latvia, Romania, Cyprus, Bulgaria, as well as in Turkey.
In several European countries (such as Belgium,
Germany, Hungary and Poland), people in low-income
groups have a greater prevalence of smoking. But the
reverse is true in other countries (such as Bulgaria, Cyprus,
Greece and Romania), where people in high-income groups
are more likely to smoke (Eurostat Statistics Database).
A new Tobacco Products Directive (2014/40/EU), adopted
i n Fe b r u a r y 2 0 1 4 , l ay s d ow n r u l e s g ov e r n i n g t h e
manufacture, presentation and sale of tobacco and related
products. The Directive notably requires that health
warnings appear on packages of tobacco and related
products, bans all promotional and misleading elements
on tobacco products, and sets out safety and quality
re q u i re m e n t s f o r e l e c t ro n i c c i g a re t t e s ( E u ro p e a n
Commission, 2014b).

The proportion of daily smokers is defined as the
percentage of the population aged 15 years and over
who report smoking every day.
The comparability of data is limited to some extent
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 some
countries, respondents are asked if they smoke
regularly, rather than daily. No recent data is available
for Croatia.
References
European Commission (2014a), Tobacco Policy, European
Commission, Brussels, available at: http://ec.europa.eu/
health/tobacco/policy/index_en.htm.
European Commission (2014b), Tobacco Products Directive,
European Commission, Brussels, available at: http://
ec.europa.eu/health/tobacco/products/index_en.htm.
WHO (2014), Tobacco, Fact Sheet No. 339, WHO, Geneva,
available at: www.who.int/mediacentre/factsheets/fs339/en/
index.html.
2.1. SMOKING AMONG ADULTS
2.1.1. Daily smoking rates among adults, 2012 and change 2002-12 (or nearest years)
Decline 2002-12 (or nearest year)

Sweden
Denmark
Finland
Luxembourg
Netherlands
Portugal
United Kingdom
Malta
Slovak Republic
Slovenia
Belgium
Romania
Lithuania
Germany
Italy
EU28
Czech Republic
Austria
Poland
Spain
Ireland
France
Cyprus
Estonia
Hungary
Latvia
Bulgaria
Croatia
Greece
13.1
17.0
17.0
17.0
18.4
18.6
19.1
19.2
19.5
20.5
20.5
20.5
21.8
21.9
22.1
22.8
22.9
23.2
23.8
23.9
24.0
24.1
25.9
26.0
26.5
27.9
29.2
35.0
38.9
-27
-35
-33
-27
-12
-15
-23
-10
-8
-12
-5
-14
-25
-7
-8
-12
Iceland
Norway
Switzerland
Turkey
Serbia
Montenegro
13.8
16.0
20.4
23.8
26.2
31.0
50
40
30
% of population aged 15 years and over
-25
-39
20
10
-35
-45
-23
-26
-60
-40
-20
0
% change over the period
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en completed with Eurostat Database (EHIS) and WHO Europe Health for All
Database.
1 2 http://dx.doi.org/10.1787/888933155493
2.1.2. Gender gap in smoking rates, 2012 (or nearest year)

Men
Women
60
50
44
40
30
24 25
22
20
23 24
20 21 21
18 18
18 19 18
16
15
15 16
14
1313
10
26
20
26
27
27
27
19
18
28
28
20
11
29
20
17
13
28
18
31
33
32
34
36
38
38
46
40
35
34
32
37
31
27
23 23
22
19
18
18
14
14
13
15 1616
13
18
11
Ic
el
a
No nd
Sw r w
i t z ay
er
la
nd
S
M
e
on r b
te ia
ne
gr
Tu o
rk
ey
Lu
Sw
xe e d e
m n
b
U n D o ur g
i t e enm
d
K i ar k
N e ngd
t h om
er
la
n
F i ds
nl
a
Sl nd
ov
en
Be ia
lg
iu
m
M
a
l
Cz
t
e c Ir e a
h lan
Re d
pu
Sl G blic
ov er
ak ma
Re n y
pu
Po blic
r tu
g
Au al
st
ria
Sp
ai
n
It a
ly
EU
2
Fr 8
an
c
Po e
la
n
Hu d
ng
Ro a r y
m
L i a ni a
th
ua
n
Es ia
to
ni
Cy a
pr
u
Cr s
oa
t
Bu i a
lg
ar
Gr i a
ee
c
La e
tv
ia
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en completed with Eurostat Database (EHIS) and WHO Europe Health for All
Database.
1 2 http://dx.doi.org/10.1787/888933155493
49
2.2. ALCOHOL CONSUMPTION AMONG ADULTS
Alcohol related harm is a major public health concern in

the European Union, both in terms of morbidity and mortality
(Rehm et al., 2009; WHO Europe, 2012). Alcohol was the third
leading risk factor for disease and mortality after tobacco and
high blood pressure in Europe in 2012 and accounted for an
estimated 7.6% of all mens deaths and 4.0% of all womens
deaths, though there is evidence that women may be more
vulnerable to some alcohol-related health conditions
compared to men (WHO, 2014). High alcohol intake is
associated with increased risk of heart, stroke and vascular
diseases, as well as liver cirrhosis and certain cancers, but
even moderate alcohol consumption increases the long
term risk of developing such diseases. 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, particularly among young people.
The EU region has the highest alcohol consumption in
the world. Measured through monitoring annual sales data,
it stands at slightly over 10 litres of pure alcohol per adult
on average across EU member states in 2012 (Figure 2.2.1).
Lithuania, Estonia and Austria reported the highest
consumption of alcohol, with 12 litres or more per adult. At
the other end of the scale, southern European countries
(Italy, Malta, Greece, Cyprus) along with Nordic countries
(Norway, Iceland, and Sweden) have relatively low levels of
consumption, with 6 to 8 litres of pure alcohol per adult.
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 traditionally beer-drinking countries and vice versa.
Major wine-producing countries such as Italy and France
have seen their alcohol consumption per capita fall
substantially since 1980 (Figure 2.2.2). On the other hand,
alcohol consumption per capita has increased at least
slightly in some Nordic countries (e.g., Sweden and
Finland), although it still remains below the EU average.
Alcohol consumption remained unchanged since 1980 in
the United Kingdom, the Czech Republic and Turkey.
Variations in alcohol consumption across countries and
over time reflect not only changing drinking habits but also
the policy responses in place to control alcohol use.
Interventions in primary health care for heavy drinkers,
regulation of advertising and sales, enforcement of drinkdriving legislation and measures affecting prices have all
proven effective in reducing alcohol consumption (WHO,
2014; OECD, forthcoming).
Although adult alcohol consumption per capita is a
useful measure to assess long-term trends, it does not
identify sub-populations at risk from harmful drinking
patterns. Heavy drinking and alcohol dependence account
for an important share of the burden of diseases associated
with alcohol. The consumption of large quantities of
alcohol in a single session, or binge drinking, is on the rise
in some countries, especially in young people. However, a
large share of the burden of diseases also occurs in
50
moderate drinkers, whose individual risk is smaller but

w h o a re i n mu ch l a rg e r nu m b e r s t h a n h e av y a n d
dependent drinkers, and in people who may be the victims
of traffic accidents and violence. Men generally drink much
more than women, and engage more often in heavy
episodic drinking (WHO, 2014; OECD, forthcoming).
Unrecorded alcohol consumption and low quality of alcohol
consumed (beverages produced informally or illegally)
remain a problem, especially when estimating alcoholrelated burden of disease among low income groups.
In 2010, the World Health Organization endorsed a
global strategy to combat the harmful use of alcohol,
through health care services for alcohol-related health
problems, restriction in the availability and marketing of
alcohol, and other measures. This initiative was boosted
in 2011 by the adoption of a new European Action Plan by
the WHO Regional Office for Europe. In addition, the
European Commission continues its efforts to reduce
alcohol related harm in line with the objectives and tools of
the EU Alcohol Strategy (European Commission, 2009). The
Commission is currently working with the Committee on
National Alcohol Policy and Action on an Action Plan on
Youth Drinking and on Heavy Episodic Drinking. The Action
Plan is expected to be endorsed by the end of 2014.

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
s t a t i s t i c s d o n o t i n c l u d e u n re c o rd e d a l c o h o l
consumption, such as home production.
References
European Commission (2009), First Progress Report on the
Implementation of the EU Alcohol Strategy, DirectorateGeneral for Health and Consumers, Brussels.
OECD (forthcoming), Alcohol and the Economics of Public
Health, OECD Publishing, Paris.
Rehm, J. et al. (2009), Global Burden of Disease and Injury
and Economic Cost Attributable to Alcohol Use and
Alcohol-use Disorder, The Lancet, Vol. 373, pp. 2223-2233.
WHO (2014), Global Status Report on Alcohol and Health 2014,
WHO, Geneva.
WHO Europe (2012), Alcohol in the European Union:
Consum ption, Harm and Policy App roaches, WHO,
Copenhagen.
2.2. ALCOHOL CONSUMPTION AMONG ADULTS
9.9
9.7
12.3
12.2
11.8
11.6
11.6
11.4
11.4
11.0
11.0
10.8
10.7
10.2
10.2
10.2
10.1
10.1
9.8
9.8
9.3
9.3
9.3
6.6
4.0
6.3
6.2
7.9
6.1
7.3
7.6
8.7
10
9.1
12
10.6
Alcohol consumption (litres per capita)

14
12.7
2.2.1. Alcohol consumption among population aged 15 years and over, 2012 (or nearest year)
1.6
4
2
It a
Sw ly
ed
en
M
al
Gr t a
ee
c
Cy e
p
Ro r u s
m
an
Fi ia
nl
D an
N e enm d
t h ar
er k
la
n
B e ds
lg
iu
Sl
m
ov
a k Sp a
Re in
pu
bl
ic
EU
Bu 2 8
lg
ar
Po i a
l
an
Un
i te L d
d at v
Ki
ng ia
do
Cr m
oa
Po t i
r tu a
Ge gal
rm
an
Lu Slov y
xe en
m ia
bo
C z H u ur g
ec ng
h
Re ar y
pu
b
Ir e l i c
la
Fr nd
an
Au ce
st
r
Es ia
t
L i oni
th a
ua
ni
a
FY
R
of Tu
M rk
ac ey
ed
o
No ni a
rw
ay
M Ic el
on an
te d
ne
gr
o
S
S w er
i t z bia
er
la
nd
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; WHO Global Information System on Alcohol and Health.
1 2 http://dx.doi.org/10.1787/888933155504
2.2.2. Trends in alcohol consumption, selected EU countries, 1980-2012

Finland
France
Italy
Sweden
EU28
Alcohol consumption (litres per capita)

20
15
10
5
1980
1985
1990
1995
2000
2005
2010
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; WHO Global Information System on Alcohol and Health.
1 2 http://dx.doi.org/10.1787/888933155504
51
2.3. USE OF ILLICIT DRUGS AMONG ADULTS
The use of illicit drugs is an important public health

issue in Europe. Almost a quarter of adults in the European
Union, or over 73 million people, have used illicit drugs at
some points in their lives. In most cases, they have used
cannabis, but some have also used cocaine, amphetamines,
ecstasy and other drugs (EMCDDA, 2014). The use of illicit
drugs, particularly among people who use them regularly, is
associated with higher risks of cardiovascular diseases,
mental health problems, accidents, as well as infectious
diseases such as HIV when the drug is injected. Illicit drug
use is a major cause of mortality among young people in
Europe, both directly through overdose and indirectly
through drug-related diseases, accidents, violence and
suicide. More than 6 000 overdose deaths and 1 700 HIV/
AIDS deaths were attributed to drug use in Europe in 2010
(EMCDDA, 2014).
Cannabis is the illicit drug most used among young
adults in Europe, especially among young men. Nearly 10%
of people aged 15 to 34 on average in EU countries
(unweighted average) reported having consumed cannabis
in the last year (Figure 2.3.1). Cannabis use is highest in the
Czech Republic, Denmark, France and Spain, with 17% or
more people aged 15 to 34 reporting to have consumed
cannabis in the last year. Cannabis use has increased over
the past decade in some Nordic countries from low levels
(Denmark, Finland and Sweden), while it has been stable or
has come down in Germany, France and the United Kingdom.
Cocaine is the most commonly used illicit stimulant in
Europe: 1.2% young adults aged 15-34, reported having used
it on average in the last year (Figure 2.3.2). The percentage of
young adults consuming cocaine is highest in Spain, the
United Kingdom, Ireland, the Netherlands and Denmark
with 2.4 % or more young adults having used cocaine at least
once in the last year. However, following a peak in 2008, a
significant reduction in cocaine use has occurred in many of
these countries (Denmark, Spain and the United Kingdom),
while the proportion was stable in others.
The use of amphetamines and ecstasy is slightly lower
than cocaine, with about 1% of young adults in EU countries
reporting to have consumed amphetamines or ecstasy in
the last year. The consumption of amphetamines tends to
be higher in some Nordic and Baltic countries (Estonia,
Finland, Sweden and Denmark) and in Germany, Croatia
a n d Po l a n d . T h e u s e o f e c s t a s y i s h i g h e s t i n t h e
Netherlands, Bulgaria, the United Kingdom and Estonia
(Figures 2.3.3 and 2.3.4). Between 2007 and 2013, the use of
amphetamines has remained relatively stable in most
European countries, while the use of ecstasy remained
stable or declined in most countries, with the exception of
Bulgaria where it went up.
The consumption of opioids (i.e., heroin and other
drugs) is responsible for the majority of drug overdose
deaths (reported in about three-quarters of fatal overdoses).
The main opioid used in Europe is heroin, but there are
52
concerns in several countries about the increasing use of

o t h e r s y n t h e t i c o p i o i d s ( s u ch a s b u p re n o r p h i n e,
methadone and fentanyl). Opioid use is highest in the
United Kingdom, Latvia and Luxembourg. Although trends
have varied across countries, the percentage of adults
consuming opioids generally appears to have declined over
the last decade in most countries.
A growing concern in many European countries relates
to the increased availability of unregulated psychoactive
substances (legal highs) which have emerged in recent
years, and some of which have been associated with
deaths. The EU Early Warning System, established
in 1997, monitors more than 375 new psychoactive
substances, which have been detected on the market. The
European Union also has a mechanism in place to assess
the risks related to new drugs, and to control those that
pose substantial health and social risks across the
European Union. The Early Warning System is coming
under increasing pressure given the growing number and
variety of new psychoactive substances appearing on the
market. EU countries and the European Commission have
agreed to increase their efforts to manage effectively the
emergence of these new substances (EMCDDA-Europol,
2014).

Data on drug use prevalence come from national
population surveys, as gathered by the European
Monitoring Centre for Drugs and Drug
Addiction (EMCDDA). The data presented in this
section focusses on the percentage of young adults
aged 15 to 34 years old reporting to have used
different types of illicit drugs in the last year. Such
estimates of recent drug use produce lower figures
than lifetime experience, but reflect better the
current situation. The information is based on the last
survey available for each country. The study year
ranges from 2004 to 2013. To obtain estimates of the
overall number of users in Europe, the EU average is
applied to countries without prevalence data.
Fo r
more
information,
www.emcdda.europa.eu/data/2014.
please
see:
References
EMCDDA European Monitoring Centre for Drugs and Drug
Addiction (2014), European Drug Report 2014: Trends and
Developments, Lisbon.
EMCDDA-Europol (2014), EMCDDA-Europol 2013 Annual
Report on the implementation of Council Decision 2005/387/
JHA, Lisbon, July.
2.3. USE OF ILLICIT DRUGS AMONG ADULTS
2.3.1. Cannabis use over the last 12 months among

people aged 15 to 34, 2013 (or nearest year)
Romania
Malta
Greece
Cyprus
Lithuania
Portugal
Hungary
Austria
Sweden
Latvia
Slovak Republic
Italy
Bulgaria
EU27
Ireland
Slovenia
Croatia
United Kingdom
Germany
Belgium
Finland
Poland
Estonia
Netherlands
Spain
France
Denmark
Czech Republic
0.6
1.9
3.2
4.2
5.1
5.1
5.7
6.6
6.9
7.3
7.3
8.0
8.3
9.5
10.3
10.3
10.5
10.5
11.1
11.2
11.2
12.1
13.6
13.7
17.0
17.5
17.6
18.5
10
15
2.3.2. Cocaine use over the last 12 months among people

aged 15 to 34, 2013 (or nearest year)
Greece
Romania
Bulgaria
Latvia
Lithuania
Poland
Hungary
Portugal
Slovak Republic
Czech Republic
Cyprus
Finland
Croatia
Austria
Slovenia
Sweden
EU26
Estonia
Italy
Germany
France
Belgium
Denmark
Netherlands
Ireland
United Kingdom
Spain
20
%
0.2
0.2
0.3
0.3
0.3
0.3
0.4
0.4
0.4
0.5
0.6
0.6
0.9
1.2
1.2
1.2
1.2
1.3
1.3
1.6
1.9
2.0
2.4
2.4
2.8
3.3
3.6
4
%
Source: European Monitoring Centre for Drugs and Drug Addiction,

European Drug Report 2014: Trends and developments.
1 2 http://dx.doi.org/10.1787/888933155512

1 2 http://dx.doi.org/10.1787/888933155512
2.3.3. Amphetamine use over the last 12 months among

people aged 15 to 34, 2013 (or nearest year)
2.3.4. Ecstasy use over the last 12 months among people

aged 15 to 34, 2013 (or nearest year)
Romania
Greece
Italy
Portugal
Slovak Republic
Cyprus
France
Lithuania
Latvia
Czech Republic
Ireland
Slovenia
Austria
EU24
Spain
United Kingdom
Hungary
Bulgaria
Denmark
Poland
Sweden
Croatia
Finland
Germany
Estonia
Italy
Sweden
Cyprus
Lithuania
Poland
Greece
France
Romania
Croatia
Portugal
Denmark
Latvia
Slovenia
Germany
Ireland
Slovak Republic
EU25
Hungary
Austria
Finland
Czech Republic
Spain
Estonia
United Kingdom
Bulgaria
Netherlands
0.0
0.1
0.1
0.1
0.3
0.4
0.5
0.5
0.6
0.8
0.8
0.8
0.9
0.9
1.1
1.1
1.2
1.3
1.4
1.4
1.5
1.6
1.6
1.8
2.5
3
%

1 2 http://dx.doi.org/10.1787/888933155512
0.1
0.2
0.3
0.3
0.3
0.4
0.4
0.4
0.5
0.6
0.7
0.8
0.8
0.9
0.9
0.9
1.0
1.0
1.0
1.1
1.2
1.4
2.3
2.4
2.9
3.1
4
%

1 2 http://dx.doi.org/10.1787/888933155512
53
2.4. 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 chronic
conditions, including hypertension, cardiovascular disease,
stroke, diabetes, certain cancers and musculoskeletal
disorders. The 2007 EU Strategy on Nutrition, Overweight
and Obesity-related Health Issues promotes a balanced diet
and active lifestyle among all the population. The European
Commission is monitoring progress in the consumption of
fruit and vegetables as one of a number of ways to offset a
worsening trend of poor diets and low physical activity
(European Commission, 2013a).
The percentage of adults reporting to consume fruit
daily varied from about 50% in Finland, Bulgaria and
Romania, to more than 70% in Italy, Malta, Ireland and the
U n i t e d K in g d o m ( Fig u re 2 . 4 . 1 ) . O n ave rag e a c ro s s
EU member states, 61% of adults reported to eat fruit daily.
Women are eating fruit more often than men in all
countries (except in Switzerland), with the largest gender
gap in Iceland, Slovenia, Germany and the Slovak Republic
(a difference of at least 20 percentage points). In many
Mediterranean countries and countries with high level of
consumption (Turkey, Greece, Cyprus, the United Kingdom,
Italy, Romania, Spain, Ireland and Malta), the gender gap is
much smaller (under 10 percentage points).
In most countries, people aged 65 and over are more
likely to eat fruit, with consumption lowest among young
people aged 15-24 years, although this is not the case in
Bulgaria and Romania where young people eat more fruit
than older people. Fruit consumption also varies by
socioeconomic status, generally being highest among
persons with higher educational levels, especially in
Bulgaria, Latvia and Romania. However, this is not the case
in some southern European countries (Cyprus, Greece,
Malta), where lower educated people eat fruit more often.
Daily vegetable consumption ranged from less than 50% in
Germany, Slovenia, Finland, Spain, Denmark, Iceland and
Hungary to more than 70% in Ireland, Belgium and the
United Kingdom. The average across 21 EU countries was 58%.
Again, more women reported eating vegetables daily. The only
exception is Bulgaria where rates are similar. The gender gap
is greatest in Germany, Finland, Switzerland, Slovenia,
Norway and Denmark, exceeding 15 percentage points.
Patterns of vegetable consumption among age groups
and educational groups are similar to those for fruit. Older
people more commonly eat vegetables daily, but this is not
the case in Bulgaria and Romania. Highly educated persons
also tend to eat vegetables more often, although the
difference between educational groups is fairly small in
countries such as Belgium, Cyprus, Greece and the
Slovak Republic.
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 at the workplace, is a policy
objective of the European Union. It features in the
EU platform for action on diet, physical activity and health,
a forum for European-level organisations including the food
i n d u s t r y, c o n s u m e r p r o t e c t i o n N G O s a n d o t h e r
stakeholders committed to improving trends in diet and
physical activity (European Commission, 2013b).

Estimates of daily fruit and vegetable consumption
are derived from national and European Health
Interview Survey questions, conducted in many
EU member states between 2007 and 2012. 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.
The definition of fruit and vegetables varies
between countries. Vegetable consumption data for
the United Kingdom and Greece include potatoes.
Data for Switzerland, Germany and Greece include
juices for both fruit and vegetable consumption. Data
for Belgium include juice for fruit consumption. Data
rely on self-report, and are subject to errors in recall.
References
Elmadfa, I. (ed.) (2009), European Nutrition and Health Report
2009, Basel, Switzerland.
European Commission (2013a), Evaluation of the Implementation of the Strategy for Europe on Nutrition, Overweight and
Obesity Related Health Issues Final Report, Directorate
General for Health and Consumers, Brussels.
European Commission (2013b), EU Platform on Diet, Physical
Activity and Health, 2013 Annual Report, European Commission, Brussels.
The availability of fruit and vegetables is the major

determinant of consumption. According to FAO data,
54
2.4. FRUIT AND VEGETABLE CONSUMPTION AMONG ADULTS
2.4.1. Daily fruit eating among adults, 2012 (or nearest year)
Women
Men
Total

80
60
40
20
el
an
ke
Ic
Tu
r
er
la
rw
Sw
it z
No
nd
ay
ar
nl
Fi
Bu
Ro
an
ia
ia
lg
ce
an
ia
Fr
an
en
ov
Sl
Es
to
ni
ia
ce
tv
ee
La
21
Gr
Ge
rm
EU
an
nd
la
Po
ai
iu
Sp
ic
lg
bl
Be
pu
ak
Re
Cy
pr
bl
pu
Re
ov
Sl
Un
Cz
i te
ec
De
us
ic
ar
ar
nm
Ki
Hu
ng
ng
la
al
Ir e
do
ta
ly
It a
nd
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en, and Eurostat Statistics Database for non-OECD countries.
1 2 http://dx.doi.org/10.1787/888933155528
2.4.2. Daily vegetable eating among adults, 2012 (or nearest year)
Women
Men
Total

100
80
60
40
20
d
an
el
ke
y
Ic
ay
Tu
r
rw
No
nd
Sw
it z
er
la
an
ia
rm
Ge
Sl
ov
en
n
ai
an
nl
Fi
k
ar
Sp
y
ar
nm
De
ng
Hu
al
bl
ta
ic
M
a
ni
ak
Re
pu
to
ov
an
ia
Es
Sl
ce
m
Ro
21
an
Fr
ia
ar
lg
Bu
EU
ic
bl
ly
pu
Re
h
nd
It a
ec
Cz
ia
la
Po
ce
tv
La
ee
us
Gr
pr
Cy
do
m
iu
Un
i te
Ki
ng
lg
Be
Ir e
la
nd
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en and Eurostat Statistics Database for non-OECD countries.
1 2 http://dx.doi.org/10.1787/888933155528
55
2.5. 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, and some forms of cancer. Because obesity is
associated with higher risks of chronic illnesses, it is linked
to significant additional health care costs.
Based on the latest available data, the majority of adults
(53%) are overweight or obese in EU countries. The
prevalence of overweight and obesity among adults
exceeds 50% in no less than 17 of EU member states.
Obesity which presents even greater health risks than
overweight varies threefold among countries, from a low
of around 8% in Romania to 25% or over in Hungary and the
United Kingdom, although some of the variations across
countries are due to different methodologies in data
collection (see box on Definitions and comparability). On
average across EU member states, one in six adult (16.7%)
was obese around the year 2012, an increase from one in
eight a decade ago (Figure 2.5.1).
Obesity has grown fairly quickly over the past ten years
in countries like France, Luxembourg, some Nordic
countries (Denmark, Finland, as well as Iceland), and the
Czech Republic. It has grown more moderately in other
countries such as Italy, Sweden, Belgium, Norway and
Switzerland. In the United Kingdom also, the obesity rate
has increased moderately over the past decade, although it
remains the second highest among EU countries.
There is little difference in obesity rate among men and
women on average across EU countries (Figure 2.5.2).
However, there are notable differences in certain countries.
Obesity among men is much greater in countries such as
Slovenia, Luxembourg and Malta, whereas the opposite is
true in Latvia, Hungary and Turkey where the obesity rate is
much higher among women.
The rise in obesity has affected all population groups,
but to different extents. Evidence from a range of OECD
countries indicates that obesity tends to be more common
in disadvantaged socio-economic groups, especially among
women (Sassi, 2010). There is also a relationship between
the number of years of education and obesity, with the
most educated people having lower rates. Again, the
gradient in obesity is stronger in women than in men
(Devaux et al., 2011).
A number of behavioural and environmental factors
have contributed to the long-term rise in overweight and
obesity rates in industrialised countries, including the
widespread availability of energy dense foods and more
time spent being physically inactive. The economic crisis is
also likely to have contributed to further growth in obesity.
Evidence from Germany, Finland and the United Kingdom
shows a link between financial distress and obesity.
Regardless of their income or wealth, people who
experience periods of financial hardship are at an increased
risk of obesity, and the increase is greater for more severe
and recurrent hardship (OECD, 2014).
56
A growing number of countries have adopted policies to

prevent obesity from spreading further. The policy mix
includes, for instance, public awareness campaigns, health
professionals training, advertising limits or bans,
restrictions on sales of certain types of food and beverages,
taxation, and labelling. Better informed consumers, making
healthy food options available, encouraging physical
activity and focussing on vulnerable groups are some of the
fields for action which have seen progress (European
Commission, 2013).
At EU level, the 2007 Strategy for Europe on Nutrition,
Overweight and Obesity-related Health Issues promotes a
balanced diet and active lifestyles. It also encourages action
by member states and civil society. A 2013 Council
Recommendation on Health-Enhancing Physical Activity
promotes sport and physical activity and the 2014 Action
Plan on Childhood Obesity aims to halt the rise in childhood
obesity by 2020 via voluntary initiatives.

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 individuals
weight in relation to height (weight/height 2 , with
weight in kilograms and height in metres). Based on
the WHO classification, adults over age 18 with a BMI
greater than or equal to 25 are defined as overweight,
and those with a BMI greater than or equal to 30
as obese.
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,
H u n g a r y, I r e l a n d , L u x e m b o u rg a n d t h e
United Kingdom, where estimates are derived from
h e a l t h e x a m i n a t i o n s . E s t i m a t e s f ro m h e a l t h
examinations are generally higher and more reliable
than from health interviews.
References
Devaux, M. et al. (2011), Exploring the Relationship
between Education and Obesity, OECD Journal: Economic
Studies 2011, No. 1, December 2011.
European Commission (2013), EU Platform on Diet, Physical
Activity and Health, 2013 Annual Report, European Commission, Brussels.
OECD (2014), Obesity Update, OECD Publishing, Paris,
www.oecd.org/els/health-systems/Obesity-Update-2014.pdf.
Sassi, F. (2010), Obesity and the Economics of Prevention Fit not
Fat, OECD Publishing, Paris, http://dx.doi.org/10.1787/
9789264084865-en.
2.5. OVERWEIGHT AND OBESITY AMONG ADULTS
2.5.1. Prevalence of obesity among adults, 2002 and 2012 (or nearest years)
2012
2002

30
25
20
15
10
21.0
17.2
10.3
10.0
28.5
24.7
23.0
23.0
22.9
21.0
19.6
19.0
18.3
16.9
16.9
16.7
16.6
15.8
15.8
15.6
15.4
14.7
14.5
13.8
13.4
12.4
12.0
11.8
11.5
7.9
10.4
y
Ic
el
an
ke
Tu
r
nd
la
rw
er
it z
Sw
No
Bu
Ro
ay
ly
lg
ar
Sw ia
Ne ed
th en
er
la
nd
Au s
st
De r ia
nm
a
Be rk
lg
iu
m
Fr
an
Ge c e
rm
a
Po ny
r tu
ga
Cy l
pr
u
Fi s
nl
an
d
Po
la
nd
Sp
a
Sl
in
ov
ak EU
Re 2 6
pu
bl
ic 1
La
tv
Sl i a
ov
en
i
Es a
to
ni
Cz
a
e c Gr e
h
Re e c e
pu
bl
ic 1
Lu
M
xe a l t
m
a
bo
ur
Un
g1
i t e Ir e l
a
d
K i nd 1
ng
do
Hu m 1
ng
ar
y1
an
m
It a
ia
1. Data are based on measured rather than self-reported height and weight.
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en completed with Eurostat Statistics Database.
1 2 http://dx.doi.org/10.1787/888933155531
2.5.2. Prevalence of obesity among men and women, 2012 (or nearest year)
Men
Women

35
30
25
20
15
10
5
Tu
r
ke
d
an
el
Ic
la
nd
ay
er
rw
Sw
No
it z
lg
a
Sw ria
ed
en
A
Ne us t
th ria
er
la
De nds
nm
Ge ar k
rm
an
Be y
lg
iu
m
Cy
pr
us
Fr
an
c
Po e
la
Sl nd
ov
en
ia
Sp
ai
n
Fi
nl
an
Po d
r tu
ga
Sl
l
ov
ak EU
Re 2 6
pu
bl
ic 1
Gr
ee
c
Es e
to
ni
a
Lu L a
xe t v i
Cz m
a
ec bo
u
h
Re r g 1
pu
bl
ic 1
M
a
l
Un
ta
i t e Ir e l
a
d
K i nd 1
ng
do
Hu m 1
ng
ar
y1
ly
It a
Bu
Ro
an
ia
1. Data are based on measured rather than self-reported height and weight.
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en completed with Eurostat Statistics Database.
1 2 http://dx.doi.org/10.1787/888933155531
57
2.6. AIR POLLUTION
Air pollution increases the risk of various health problems

(including of course respiratory diseases, but also lung cancer
and cardiovascular diseases), with children and older people
being particularly vulnerable. According to WHO estimates,
nearly 500 000 deaths in Europe in 2012 were linked to
exposure to outdoor air pollution (WHO, 2014).
Air pollution concentrations are greater in urban areas
in all countries. Of all air pollutants, fine particulate matter
(PM) has the greatest effect on human health. Most fine
particulate matter comes from fuel combustion, including
from vehicles, power plants, industries and households.
Despite a reduction in the emission of PM 10 over the
past decade, a large percentage of the urban population in
EU countries continued to live in 2011 in areas where PM10
levels exceeded the EU and WHO threshold. The emission
of PM10 across EU countries decreased by 14% between 2002
and 2011, and the exposure of the urban population to PM10
also fell in most countries (Figure 2.6.1). However, this was
not the case in some central and eastern European
countries (such as Bulgaria, Poland and the Slovak Republic)
where urban population exposure to PM 10 increased
sometimes dramatically over the past decade. Population
exposure to PM10 is also high in Turkey and Serbia.
In the European Union as a whole, one-third of the
population lived in areas where the EU air quality limits for
particulate matter was exceeded in 2011. This share varied
from 20 to 44% between 2001 and 2011, reaching a peak
in 2003 and 2006, and rising again in 2011 (Figure 2.6.2). The
proportion of the EU urban population exposed to PM10
levels exceeding the WHO air quality guidelines, which are
stricter than the threshold set by EU legislation, was much
higher, reaching 88% of the total urban population in 2011
(European Environment Agency, 2013).
A large percentage of people living in urban areas in
EU countries are also exposed to other air pollutants which
concentrations exceed the thresholds set in the EU
legislation and the WHO air quality guidelines. In the
period from 2001 to 2011, between 14 and 65 % of the urban
population in EU countries was exposed to ozone (O 3 )
concentrations exceeding the EU target value set for the
protection of human health. This proportion reached a
peak in 2003 and another peak in 2006, but has declined
since then. Similarly, in the period 2001-11, between 5% and
23% of the urban population in EU countries was exposed to
nitrogen dioxide (NO2) concentrations above the EU limit
for the protection of human health. This proportion also
peaked in 2003 and has come down since then.
pollutants emitted by tall chimneys can promote better

dilution in the air and lowers local concentrations of
pollutants. However, this leads to wider dispersion of
pollution and trans-boundary air pollution. Stricter
operating practices and the use of modern techniques have
resulted in a sizeable reduction in the amount of pollutants
emitted from power stations.

The indicators presented here refer to population
exposure to particulate matter 10 (PM10) and other
pollutants in cities with more than 100 000 population.
The estimates represent the average annual exposure
level of the average urban resident.
PM 10 refers to suspended particulates less than
t e n m i c ro n s i n d i a m e t e r t h a t a r e c a p a b l e o f
penetrating deep into the respiratory tract and
causing significant health damage. Fine particulates
smaller than 2.5 microns in diameter (PM2.5) cause
even more severe health effects because they
penetrate deeper into the respiratory tract and are
potentially more toxic as they may include heavy
metals and toxic organic substances (OECD, 2013).
Ozone is a secondary pollutant (meaning that it is
not emitted directly by any emission source), formed
in the lower part of the atmosphere from complex
chemical reactions following emissions of precursor
gases such as nitrogen dioxides (which are emitted
during fuel combustion).
Data on exposure to air pollution are available for
most but not all European countries. Further efforts
are needed to monitor or estimate overall population
exposure.
References
European Environment Agency (2013), Air Quality in Europe
2013 Report, Copenhagen.
OECD (2013), Environment at a Glance 2013: OECD Indicators,
9789264185715-en.
WHO (2014), Burden of Disease from Ambient Air Pollution for
2012, Geneva, www.who.int/phe/health_topics/outdoorair/
databases/AAP_BoD_results_March2014.pdf?ua=1.
While there have been improvements in reducing

emissions of a number of air pollutants in the past
decade, further efforts are needed to reduce air pollution,
notably by reducing emissions from transports due to
motor vehicles, but also from power stations which produce
more pollution than any other industry. Better dispersion of
58
2.6. AIR POLLUTION
2.6.1. Urban population exposure to air pollution by particulate matter (PM10), 2001 and 2011 (or nearest years)
2011
53
58
58
2001
Annual average concentration of PM10 in micrograms per cubic meter
60
39
20
23
34
33
32
31
29
27
27
27
25
25
23
23
23
23
18
13
12
12
17
20
18
21
30
27
40
36
39
50
10
an
d
r
Sw wa
y
it z
er
la
n
Se d
rb
ia
Tu
rk
ey
No
el
Ic
to
n
Sw ia
ed
en
L u Ir e l a
Un xem n d
i te bo
d
u
Ki rg
ng
do
Ge m
rm
an
y
Sp
ai
n
La
t
Li via
th
ua
ni
a
Fr
Ne an
ce
th
er
la
nd
s
EU
25
Be
lg
iu
m
Au
st
r
C z Po i a
ec r tu
h
Re g a l
pu
b
Sl lic
ov
en
ia
It a
ly
Sl
H
ov un
ak ga
r
Re y
pu
bl
i
Cy c
pr
u
Po s
la
n
Ro d
m
an
Bu i a
lg
ar
ia
Es
an
nl
Fi
De
nm
ar
Source: European Environment Agency (EEA), Air quality in Europe 2013 Report.
1 2 http://dx.doi.org/10.1787/888933155540
2.6.2. EU urban population exposed to air pollution exceeding EU air quality standards, 2001-11
Ozone
Particulate matter 10
Nitrogen dioxide
% of urban population
70
60
50
40
30
20
10
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Source: European Environment Agency (EEA), Air quality in Europe 2013 Report.
1 2 http://dx.doi.org/10.1787/888933155540
59

OECD 2014
Chapter 3
Health care resources and activities
3.1. Doctors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
62
3.2. Consultations with doctors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
64
3.3. Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
66
3.4. Medical technologies: CT scanners and MRI units . . . . . . . . . . . . . . .
68
3.5. Hospital beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
70
3.6. Hospital discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
72
3.7. Average length of stay in hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .
74
3.8. Cardiac procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
76
3.9. Cataract surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
78
3.10. Hip and knee replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
80
3.11. Pharmaceutical consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
82
61
3.1. DOCTORS
The number of doctors per capita varies widely across

European countries. In 2012, Greece had, by far, the highest
number, with 6.2 doctors per 1 000 population, nearly twice
the EU average of 3.4. Following Greece was Austria, with
4.9 doctors per 1 000 population. The number of doctors
per capita was also relatively high in Lithuania and Portugal
( a l t h o u g h t h e nu m b e r rep o r t e d i n Po r t u g a l i s a n
overestimation as it comprises all doctors licensed to
practice, including some who may not be practising). The
number of doctors per capita was lowest in Poland,
R o m a n i a a n d S l ov e n i a a m o n g E U m e m b e r s t a t e s
(Figure 3.1.1).
Since 2000, the number of physicians per capita has
increased in all European countries, except in France where
it has remained stable. On average across EU member
states, physician density increased from 2.9 doctors per
1 000 population in 2000 to 3.4 in 2012. The rise in the
number of doctors per capita was particularly rapid in
Greece, but most of the growth occurred before the
economic crisis started in 2008. The growth rate has also
been very strong in the United Kingdom, which started
from the second lowest level in 2000, thereby narrowing the
gap with other EU countries (Figure 3.1.1).
In most European countries, the absolute number of
doctors has increased both before and after the 2008-09
economic crisis, although the number has stabilised in
some countries hard hit by the recession such as Greece. In
the United Kingdom, there were over 10% more employed
doctors in 2012 compared with 2008 (Figure 3.1.2). Looking
at the entire period from 2000 to 2012, there were 50% more
doctors in the United Kingdom in 2012 compared with 2000.
In the Netherlands also, the number of doctor has increased
steadily since 2000, and there were over one-third more
doctors in 2011 (latest year available) compared with 2000.
In Germany, the number of doctors has increased slightly
more rapidly since 2008 than between 2000 and 2008;
overall, there were about 20% more doctors in 2012
compared with 2000.
There continues to be concerns in many European
countries about current or future possible shortages of
doctors, notably for certain categories of doctors (e.g.,
primary care doctors) or in rural areas (see Indicator 5.3).
These concerns are linked to a large extent to the ageing of
the medical workforce. In 2012, on averag e across
EU countries, one-in-three doctor (33%) was over 55 years of
age, up from one-in-six (17%) in 2000. While many of these
doctors may be expected to retire over the coming decade,
one noticeable trend observed in many countries in recent
years is that a larger number of doctors continue to practice
after age 65. In France, the continued increase in the
absolute number of doctors since 2008 has been driven
mainly by a growing number of doctors remaining in
activity beyond age 65 (DREES, 2014).
Many countries have also anticipated the upcoming
retirement of a significant number of doctors by increasing
their education and training efforts to make sure that there
would be enough new doctors to replace those who will be
retiring. In some countries (e.g., the United Kingdom and
62
the Netherlands), there are even concerns now that there

might be surpluses of certain categories of doctors in the
years ahead. This has led to recommendations to reduce
slightly student intakes in medical schools or post-graduate
training for certain specialties (e.g., CfWI, 2012; ACMMP,
2014).
In most countries, concerns about growing shortages of
primary care doctors reflect the growing imbalance in the
number of generalists versus specialists. In response to
these concerns, many countries have taken steps to
improve the number of post-graduate training places
(internship and residency posts) and the attractiveness of
general practice by improving working conditions and
remuneration levels. A number of countries have also
introduced or extended the roles of other health care
providers, such as advanced practice nurses, to respond to
growing demands for primary care (Delamaire and
Lafortune, 2010).
The European Joint Action on Health Workforce
Planning and Forecasting, launched in 2012, aims to
promote collaboration and exchange between member
states to better prepare the future health workforce.

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.
References
ACMMP Advisory Committee on Medical Manpower Planning (2014), The 2013 Recommendations for Medical Specialist Training, Capaciteitsorgaan, Utrecht.
CfWI Centre for Workforce Intelligence (2012), A Strategic
Review of the Future Healthcare Workforce: Informing Medical
and Dental Student Intakes, London.
Delamaire, M.L. and G. Lafortune (2010), Nurses in Advanced
Roles: A Description and Evaluation of Experiences in
12 Developed Countries, OECD Health Working Paper,
No. 54, OECD Publishing, Paris, http://dx.doi.org/10.1787/
5kmbrcfms5g7-en.
DREES Direction de la recherche, des tudes, de l'valuation et des statistiques (2014), La dmographie des mdecins (Medical demography), Paris, April.
European Joint Action on Health Workforce Planning and
Forecasting (2014), Newsletter, March 2014, available at
http://euhwforce.weebly.com.
3.1. DOCTORS
3.1.1. Practising doctors per 1 000 population, 2000 and 2012 (or nearest year)
2000
2012
6.2

7
2.0
1.7
2.7
3.1
3.9
3.6
4.2
2.5
2.2
2.7
2.5
2.8
2.8
2.9
3.0
2.9
3.1
3.1
3.3
3.1
3.3
3.3
3.4
3.4
3.5
3.5
3.7
3.7
3.9
3.8
4.0
3.9
4.4
4.1
4.9
N
S w or w
i t z ay
er
la
Ic nd
el
FY
an
R
of S d 1
M er b
ac ia
M e do
on n
te ia
ne
g
Tu ro
rk
ey 1
Li s tr i
th a
u
Po a ni
r tu a
Ge gal 2
rm
a
Sw ny
ed
en
It a
ly
Sp
C z B a in
e c ul g
h
Re ar i a
pu
De
bl
ic
nm
ar M a
k ( lt a
20
Sl
09
ov
ak E )
Re U 2
pu 8
bl
Fr ic 1
an
Fi ce 1
nl
an
Es d 1
to
n
Ne L a ia
th t v
er i a
la
n
Hu d s 1
ng
a
Cy r y
pr
Be us
lg
iu
m
L u Cr o
x
Un e a t i
i t e mb a
d ou
Ki rg
ng
do
Ir e m
l
Sl and
ov
Ro e n i a
m
an
Po i a
la
nd
ee
Gr
Au
ce 1
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 physicians who are licensed to practice.
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; Eurostat Statistics Database; WHO Europe Health for All Database.
1 2 http://dx.doi.org/10.1787/888933155557
3.1.2. Evolution in the number of doctors, selected EU countries, 2000 to 2012 (or nearest year)
Netherlands
France
Greece
Czech Republic
Germany
United Kingdom
Portugal1
Spain
Index (2000 = 100)

160
Index (2000 = 100)

160
140
140
120
120
100
2000
2002
2004
2006
2008
2010
2012
100
2000
2002
2004
2006
2008
2010
2012
1. Data refer to doctors licensed to practice.

Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; Eurostat Statistics Database.
1 2 http://dx.doi.org/10.1787/888933155557
63
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, 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, Iceland and
Luxembourg), patients may approach specialists directly.
The number of doctor consultations per person per year
is highest in Hungary, the Slovak Republic and the
Czech Republic, and the lowest in Cyprus, Finland and
Sweden (Figure 3.2.1). The EU average is 6.3 consultations
per person per year, with most member states reporting
four to seven visits per person per year. Cultural factors
appear to play a role in explaining some of the variations
a c ro s s c o un t r i es , a l t h o u g h c e r t a i n h e a l t h s y s t e m
characteristics may also play a role. Some countries which
pay their doctors mainly by fee-for-service tend to have
above-average 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 Finland and Sweden, the low number of doctor
consultations may also be explained partly by the fact that
nurses and other health professionals play an important
role in primary care 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.
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. A 2012 OECD study, using the first
wave of the European health interview survey and other
national surveys carried out between 2006 and 2009,
provided evidence on inequality in doctor consultations by
income group in a number of European countries,
particularly for consultations with medical specialists
(Devaux and de Looper, 2012).
The information on doctor consultations can also be
used to estimate the number of consultations per doctor.
This indicator should not be taken as a measure of doctors
productivity, since consultations can vary in length and
effectiveness, and because it excludes the work doctors do
on hospital inpatients, administration and research. There
are other comparability limitations reported in the box
below on Definition and comparability. Keeping these
reservations in mind, the estimated number of consultations
64
per doctor is highest in central and eastern European

countries (Hungary, the Slovak Republic, Poland and the
Czech Republic) and in Turkey, and is the lowest in Sweden
(Figure 3.2.2).

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
non-response rates.
In Hungary, the figures include consultations for
diagnostic exams, such as CT and MRI scans (resulting
in an over-estimation). The figures for the Netherlands
exclude contacts for maternal and child care. The data
for Portugal exclude visits to private practitioners,
while those for the United Kingdom exclude
consultations with specialists outside hospital
outpatient departments (resulting in an underestimation). In Germany, the data include only the
number of cases of physicians treatment according to
reimbursement regulations under the Social Health
Insurance Scheme (a case only counts the first contact
over a three-month period, even if the patient
consults a doctor more often, leading to an underestimation of consultations with doctors). Telephone
contacts are included in some countries (e.g. Ireland,
Spain and the United Kingdom). In Turkey, a majority
of consultations with doctors occur in outpatient
departments in hospitals.
References
Delamaire, M.L. and G. Lafortune (2010), Nurses in
Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries, OECD Health Working
Paper No. 54, OECD Publishing, Paris, http://dx.doi.org/
10.1787/5kmbrcfms5g7-en.
Devaux, M. and M. de Looper (2012), Income-related
Inequalities in Health Service Utilisation in 19 OECD
countries, OECD Health Working Papers No. 58, OECD
Publishing, Paris, http://dx.doi.org/10.1787/5k95xd6stnxt-en.
3.2. CONSULTATIONS WITH DOCTORS
3.2.1. Number of doctor consultations per capita, 2012 (or nearest year)
Annual consultations per capita
12
10
8
6
4
2
te
ne
gr
ay
on
FY
of
h
ec
rw
No
ia
an
el
on
ed
ac
Ic
ia
ke
rb
Se
Tu
r
Re i c
pu
Ge blic
rm
Li any
th
ua
n
Be ia
lg
iu
m
Sp
ai
n
It a
l
Po y
la
nd
La
tv
i
Cr a
oa
tia
Au
st
ria
Lu Fr a
xe n c
m e
bo
ur
g
EU
25
Es
to
Sl ni a
o
ve
N
Un e t h e ni a
i te r la
d
n
K i ds
ng
do
Ro m
m
a
D e ni a
nm
Po ar k
r tu
ga
Ir e l
la
n
Sw d
ed
e
Fi n
nl
an
Cy d
pr
us
bl
pu
Cz
Sl
ov
ak
Re
Hu
ng
ar
1 2 http://dx.doi.org/10.1787/888933155568
3.2.2. Estimated number of consultations per doctor, 2012 (or nearest year)
Annual consultations per doctor
5 000
4 500
4 000
3 500
3 000
2 500
2 000
1 500
1 000
500
of
No
rw
ay
an
Ic
el
gr
ne
ed
on
FY
ac
M
ec
te
rb
on
ia
ia
y
ke
Se
Tu
r
i
Po c
la
n
Re d
pu
b
B e lic
lg
iu
Ge m
rm
a
Sl n y
o
Lu ve
xe ni a
m
bo
ur
g
F
Ne r an
ce
th
er
la
nd
Cr s
oa
tia
La
tv
Es ia
to
ni
a
EU
24
Sp
ai
Un
n
i te
I
ta
d
l
Ki
ng y
do
m
Ro
m
a
L i ni a
th
ua
ni
Au a
st
De ria
nm
ar
Ir e k
la
n
Fi d
nl
an
Cy d
pr
u
Sw s
ed
en
bl
Re
pu
Cz
Sl
ov
ak
Hu
ng
ar
1 2 http://dx.doi.org/10.1787/888933155568
65
3.3. NURSES
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 retention rates in the profession, even as the
economic crisis has squeezed health budgets.
This section presents data on the number of nurses,
distinguishing where applicable professional (or qualified)
nurses from associate professional (or qualified auxiliary)
nurses (who are trained at a lower level and perform lower
tasks). These data do not include nursing aids or health care
assistants, who are not recognised as nurses, but may
nonetheless provide a lot of assistance in patient care.
On average across EU countries, there were about
eight nurses per 1 000 population in 2012. The number of
nurses per capita was highest in Switzerland, Norway,
Denmark, Finland, Ireland, Luxembourg and the Netherlands.
In Switzerland and Denmark, around two-thirds of nurses
are professional (or qualified) nurses while the other
one-third are associate professional (or qualified auxiliary)
nurses. In other countries such as Belgium, France, Italy and
Spain, there are no associate professional nurses as such,
but a large number of nursing aids (or health care assistants)
provide assistance to nurses. Greece had the fewest number
of nurses among EU countries (including both professional
and associate professional), followed by Bulgaria and
Cyprus.
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 Malta,
Portugal and Spain. In Estonia, the absolute number of nurses
and density per capita increased up to 2008, but decreased
slightly after the economic crisis, from 6.4 nurses per
1 000 population in 2008 to 6.2 in 2011 and 2012, although it
remained higher than in 2000 (5.8 per 1 000 population).
In 2012, the number of nurses per doctor ranged from
four or more in Denmark, Finland, Luxembourg and Ireland,
to less than one nurse per doctor in Greece (Figure 3.3.2).
The average across EU member states was about two-anda-half nurses per doctor, with many countries reporting
between two to four nurses per doctor. In Greece, there is
evidence of an oversupply of doctors and undersupply of
nurses, resulting in an inefficient allocation of resources.
Promoting a greater retention of nurses in the
profession is an important issue in many European
countries to reduce any current or future shortages. A
2 0 0 9 - 1 0 s u r vey o f nu r s e s wo r k i n g in h o s p i t a l s in
12 European countries found large variations in rates of job
dissatisfaction among nurses, ranging from 11% in the
Netherlands up to 56% in Greece, and in their intention to
66
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,
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 (Delamaire
and Lafortune, 2010).

The number of nurses includes those providing
services directly to patients (practising), but in some
countries it also includes those working as managers,
educators or researchers (professionally active). In
countries where there are different levels of nurses,
the data include both professional (or qualified)
nurses who have a higher level of education and
perform higher level tasks and associate professional
(or qualified auxiliary) nurses who have a lower level of
education but are nonetheless recognised and registered
as nurses. Nursing aids (or health care assistants) who
are not recognised as nurses are excluded.
Midwives are also not included, except in some
countries where they are considered specialist nurses.
Austria reports only nurses working in hospitals
(resulting in an underestimation). Data for Germany
does not include about 277 500 nurses (representing
an additional 30% of nurses) who have three years of
education and are providing services for the elderly.
References
Aiken, L.H. et al. (2012), Patient Safety, Satisfaction and
Quality of Hospital Care: Cross Sectional Surveys of
Nurses and Patients in 12 Countries in Europe and in the
United States, British Medical Journal, Vol. 344, p. e1717,
20 March 2012.
Delamaire, M.L. and G. Lafortune (2010), Nurses in
Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries, OECD Health Working
Paper No. 54, OECD Publishing, Paris, http://dx.doi.org/
10.1787/5kmbrcfms5g7-en.
3.3. NURSES
3.3.1. Practising nurses per 1 000 population, 2012 and change between 2000 and 2012 (or nearest year)
Professional nurses (or one category of nurse only)
Associate professional nurses
Denmark (2009)
Finland
Ireland1
Luxembourg
Netherlands1
Germany
Sweden
Belgium
France 1
United Kingdom
Slovenia
Czech Republic
EU28
Austria 2
Lithuania
Malta
Italy1
Hungary
Estonia
Slovak Republic1
Romania
Portugal1
Croatia
Poland
Spain
Latvia
Cyprus1
Bulgaria
Greece1
15.4
14.1
12.6
11.9
11.9
11.3
11.1
9.5
9.1
8.2
8.2
8.1
8.0
7.8
7.5
6.7
6.4
6.3
6.2
5.8
5.8
5.8
5.7
5.5
5.2
5.0
4.7
4.3
3.6
16.6
16.5
7.5
6.3
5.3
1.8
10
1.3
1.5
1.0
1.4
2.6
1.5
0.5
1.3
0.7
-0.1
5.0
1.5
0.5
-2.0
1.3
3.9
1.7
0.8
3.2
0.7
1.0
1.0
2.5
2.3
Switzerland
Norway
Iceland1
FYR of Macedonia1
Serbia
Montenegro
Turkey1
15.2
15
2.5
2.5
0.3
3.2
1.1
2.4
0.7
0.2
4.7
-3
3
6
Average annual growth rate (%)
1. Data include not only nurses providing direct care to patients, but also those working in the health sector as managers, educators, researchers, etc.
2. Austria reports only nurses employed in hospital.
1 2 http://dx.doi.org/10.1787/888933155579
3.3.2. Ratio of nurses to physicians, 2012 (or nearest year)

5
4.4 4.3
4.3
4.3 4.3
4.0
3.9
3.8
3.2 3.2
3.0 3.0
2.8 2.7
2.5
2.7
2.3 2.2
2.2
2.0
1.9 1.9 1.9
2.0
1.7 1.7 1.6
1.6 1.6 1.5
1.5
1.4 1.4
1.1
1.0
1
0.6
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ar
k(
20
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EU
C z Ro 2 8
ec m
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al
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ua
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pr
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tv
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ce
Sw
it z
er
la
Ic nd
el
a
N nd
M or
on w a
te y
ne
FY
g
R
of S ro
M er b
ac ia
ed
on
Tu ia
rk
ey
Note: 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. Austria reports only nurses employed in hospital.
1 2 http://dx.doi.org/10.1787/888933155579
67
3.4. MEDICAL TECHNOLOGIES: CT SCANNERS AND MRI UNITS
Recent advances in medical imaging technologies are

improving diagnosis and treatment of diseases, but they are
also increasing health spending. This section presents data
on the availability and use of two diagnostic imaging
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. In 2012, Italy, Greece, Finland and Cyprus had
the highest number of MRI units per capita among
EU member states, while Greece, Italy, Latvia and Cyprus
had the highest number of CT scanners per capita. Iceland
and Switzerland also have a large number of both MRI and
CT scanners on a per capita basis (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 equipment show
that the number of MRI exams per capita in 2012 (or
nearest year) in EU countries was highest in Germany,
France, Luxembourg, Belgium and Greece. The number of
CT exams per capita was highest in the same group of
countries, with the exception of Germany.
of both types of diagnostic exams is generally much lower,

the variation across regions was even greater, with almost a
four-fold difference between those Primary Care Trusts
(PCTs) that had the highest rates and lowest rates of MRI
and CT exams in 2010/11 (OECD, 2014).
Clinical guidelines have been developed in some
European countries to promote a rational use of these
diagnostic technologies. 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).
A 2013 Council Directive (2013/59/EURATOM), which is
t o b e i m p l e m e n t e d by E U m e m b e r s t a t e s i n 2 0 1 8 ,
establishes legal requirements and an appropriate regime
of regulatory control designed to provide basic safety
standards for protection against the dangers from exposure
to ionising radiation, based on the principles of justification,
optimisation and dose limitation.

While the data in most countries cover CT scanners
and MRI units installed both in hospitals and the
ambulatory sector, the data coverage is more limited
in some countries. CT scanners and MRI units outside
hospitals are not included in some countries (e.g.,
Belgium, Finland, Germany and Portugal, as well as
Switzerland for MRI units). For the United Kingdom,
the data only include scanners in the public sector. No
data is available for Sweden.
Similarly, MRI and CT exams performed outside
hospitals are not included in some countries (e.g.,
A u s t r i a , C y p r u s , I r e l a n d , Po r t u g a l a n d t h e
United Kingdom). Furthermore, MRI and CT exams for
Ireland only cover public hospitals. The Netherlands
only report data on publicly-financed exams.
In Greece, most CT and MRI scanners are installed in

privately-owned diagnostic centres and clinics and only a
minority are found in public hospitals. While there are
clinical guidelines issued by the Hellenic Radiology Society
regarding the use of CT and MRI scanners, these are not
used for patient referrals. The Ministry of Health, in order to
control the diffusion of CT and MRI scanners, issued a
ministerial decree in 2010, setting out certain criteria
concerning the purchase of imaging equipment in the private
sector. One of the main criteria was based on a minimum
threshold of population density (30 000 population for CT
scanners and 40 000 for MRIs). However, this criterion has
been withdrawn by a new ministerial decree in October 2013,
which will probably lead to an increase in the number of CT
and MRI scanners in Greece.
References
There are large variations in the use of CT and MRI

scanners not only across countries, but also within
countries. For example, in Belgium, there was almost a twofold variation in the use of MRI and CT exams between
those provinces with the highest and lowest rates in 2010.
In the United Kingdom (England) where the utilisation rate
OECD (2014), Geographic Variations in Health Care Use: What Do

We Know and What Can Be Done to Improve Health System
Performance?, OECD Publishing, Paris, http://dx.doi.org/
10.1787/9789264216594-en.
68
European Union (2013), Council Directive 2013/59/EURATOM Laying Down Basic Safety Standards Against the
Dangers Arising from Exposure to Ionising Radiation,
Official Journal of the European Union, L13/1, 17-1-2014.
NICE National Institute for Health and Clinical Excellence
(2012), Published Diagnostics Guidance, London and
Manchester, available at guidance.nice.org.uk/DT/Published.
3.4. MEDICAL TECHNOLOGIES: CT SCANNERS AND MRI UNITS
3.4.1. MRI units, 2012 (or nearest year)

Italy
Greece
Finland
Cyprus
Austria
Denmark (2009) 1
Spain
Luxembourg
Ireland
Netherlands
Germany1
Belgium1
EU27
Lithuania
Croatia
Estonia
Latvia
Slovenia
France
Bulgaria
Malta
Czech Republic
United Kingdom
Portugal1
Slovak Republic
Poland
Romania
Hungary
3.4.2. CT scanners, 2012 (or nearest year)

24.6
23.4
21.6
19.7
19.1
15.4
14.8
13.2
12.4
11.8
11.3
10.6
10.5
10.0
9.8
9.8
9.8
8.8
8.7
7.4
7.2
7.0
6.8
6.4
6.3
5.4
3.8
2.8
Iceland
Switzerland1
Turkey
21.8
20.8
9.9
10
15
Greece
Italy
Latvia
Cyprus
Bulgaria
Austria
Denmark
Malta
Luxembourg
Lithuania
Finland
EU27
Portugal1
Germany1
Estonia
Spain
Ireland
Croatia
Slovak Republic
Poland
Czech Republic
Belgium1
France
Slovenia
Netherlands
Romania
United Kingdom
Hungary1
34.8
33.3
32.5
32.4
32.2
29.8
29.3
28.6
24.5
23.8
21.8
20.0
18.6
18.6
17.4
17.1
16.8
15.7
15.5
15.2
15.0
14.3
13.5
12.6
10.9
9.2
8.7
7.7
Iceland
Switzerland
Turkey
20
25
Per million population
40.5
34.6
13.6
10
15
20
25
30
35
40 45
Per million population
Note: The EU average does not include countries which only report
equipment in hospital.
1. Equipment outside hospital is not included.
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en;
Eurostat Statistics Database.
1 2 http://dx.doi.org/10.1787/888933155582
Note: The EU average does not include countries which only report
equipment in hospital.
1. Equipment outside hospital is not included.
1 2 http://dx.doi.org/10.1787/888933155582
3.4.3. MRI exams, 2012 (or nearest year)
3.4.4. CT exams, 2012 (or nearest year)
95.2
Germany (2009)
France
Luxembourg
Belgium
Greece
Denmark1
Spain
Austria1
Netherlands
Estonia
EU26
Czech Republic
Finland
Slovak Republic
United Kingdom1
Hungary
Croatia
Slovenia
Latvia
Lithuania
Portugal1
Malta
Poland
Ireland1
Cyprus1
Bulgaria
Romania1
Luxembourg
Greece
Belgium
France
Latvia
Austria1
Portugal1
Denmark1
Germany
Slovak Republic
Cyprus1
EU25
Czech Republic
Spain
Hungary
Lithuania
United Kingdom1
Croatia
Ireland1
Netherlands
Malta
Slovenia
Bulgaria
Poland
Finland
Romania1
82.0
78.8
77.0
67.6
67.0
64.5
51.0
50.0
46.8
46.5
43.2
42.1
40.9
40.4
34.1
33.5
33.2
28.4
27.7
26.7
22.0
17.9
17.7
7.2
6.6
1.7
Turkey
Iceland
Serbia
114.3
79.3
10.5
50
100
1. Exams outside hospital are not included.

1 2 http://dx.doi.org/10.1787/888933155582
205.0
180.3
178.5
172.1
154.0
133.4
132.1
130.1
117.1
107.6
105.5
98.0
94.5
90.4
86.2
77.4
75.7
72.6
71.3
70.8
65.3
52.6
46.7
37.3
29.1
13.0
Iceland
Turkey
Serbia
177.5
130.7
60.3
50
100
150
200
250
1. Exams outside hospital are not included.

1 2 http://dx.doi.org/10.1787/888933155582
69
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.
Since 2000, the number of hospital beds per population
has decreased in all EU countries, except Greece where it
increased slightly although the number has started to come
down since 2010. On average across EU member states, the
number fell by close to 2% per year, coming down from
6.4 beds per 1 000 population in 2000 to 5.2 in 2012
(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, the Slovak Republic,
Estonia and Finland.
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).
In 2012, Germany and Austria 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. Sweden, the United Kingdom and
Ireland had a relatively low number of hospital beds
(although the data in the United Kingdom and Ireland do
not include beds in private hospitals). Turkey also had a
relatively low number of beds per capita in 2012, although
their number increased markedly since 2000.
More than two-thirds (69%) 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, almost 30% of hospital
beds are allocated for long-term care, because local
governments (municipalities) use beds in health care
centres (which are defined as hospitals) for at least some of
the needed institution-based long-term care. In Belgium
and the Netherlands, close to 30% of hospital beds are
devoted to psychiatric care.
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 2012, accompanied by a decrease in the share of
beds in public hospitals from 45% to 40%. The remaining
beds were in private not-for-profit hospitals (whose share
70
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 24%
in 2012, while the proportion of beds in public hospitals
decreased from 66% in 2000 to 62% in 2012 (OECD, 2014).
In some 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 93% in 2012). In the United Kingdom, the
occupancy rate of curative care beds has remained
relatively stable, at 84% between 2000 and 2010 (latest year
available) (OECD, 2014).

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 longterm 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.
References
European Observatory on Health Systems and Policies
(2012), Eurohealth Health Systems and the Financial Crisis,
Vol. 18, No. 1.
OECD (2014), OECD Health Statistics 2014, OECD Publishing,
Paris, http://dx.doi.org/10.1787/health-data-en.
3.5. HOSPITAL BEDS
3.5.1. Hospital beds per 1 000 population, 2000 and 2012 (or nearest year)
2000
2012

10
Ge
rm
an
Au y
s
Li tr i
th a
u
C z H ani a
e c un
h ga
Re r y
pu
bl
Po ic
la
Ro n d
m
a
Bu ni a
lg
ar
Fr i a
an
Be ce
lg
iu
Cr m
oa
Sl
tia
ov
ak L at
Re v i a
pu
b
Es lic
to
n
Fi ia
nl
an
Lu E d
xe U 2
m 8
Ne
bo
th
ur
er
l a Gr e g
nd e
s ( ce
20
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ov
en
ia
M
al
Cy ta
pr
us
I
Po t al y
rt
De uga
nm l
ar
k
Sp
Un
ai
n
i t e Ir e
d
K i l and
ng
d
S w om
ed
en
Se
rb
ia
F Y Sw (20
0
R
of it ze 9 )
M rla
ac nd
M e do
on n
te ia
ne
N o gr o
rw
a
Ic y
el
an
Tu d
rk
ey
1 2 http://dx.doi.org/10.1787/888933155597
3.5.2. Hospital beds by function of health care, 2012 (or nearest year)
Curative care beds
%
100
Psychiatric care beds
Long-term care beds
Other hospital beds
80
60
40
20
Ge
rm
an
Au y
s
Li tr ia
th
ua
C z Hu ni a
ec ng
h
Re ar y
pu
Ro b l i c
m
an
Po i a
la
Bu nd
lg
ar
i
Fr a
an
Sl
c
ov B el e
a k giu
Re m
pu
bl
Cr i c
oa
tia
La
tv
Es ia
to
n
Fi ia
nl
an
d
Lu E
x U
Gr em 2 8
e e bo
c e ur
(2 g
Ne
00
th
9)
er
la
M
nd a
s ( lt a
20
0
Sl 9 )
ov
en
C y ia
pr
us
It a
Po l y
r tu
De gal
nm
ar
k
Sp
ai
Un
n
i t e Ir e
l
d
K i and
ng
do
Sw m
ed
en
F Y Sw
R
i
o f t z er
M la
ac nd
ed
on
No ia
rw
Ic a y
el
an
Tu d
rk
ey
Note: Countries ranked from highest to lowest total number of hospital beds per capita.
1 2 http://dx.doi.org/10.1787/888933155597
71
3.6. HOSPITAL DISCHARGES
Hospital discharge rates measure the number of

patients who leave a hospital after staying at least one
night. 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
demand for hospital services, 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 2012, hospital discharge rates were the highest in
Austria, Bulgaria, Germany and Lithuania (Figure 3.6.1).
They were the lowest in Cyprus, Spain and Portugal. 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,
Romania, Greece and Poland), discharge rates have
increased between 2000 and 2012. In a second group of
countries (including the Czech Republic, Denmark, Sweden,
the United Kingdom and Ireland), they have remained
stable, while in the third group (including Hungary, Finland,
Estonia, France, Luxembourg and Italy), discharge rates fell
between 2000 and 2012.
Trends in hospital discharges reflect the interaction of
several factors. Demand for hospitalisation may grow as
populations age, given that older population groups
account for a disproportionately high percentage of
hospital discharges. For example, in Austria and Germany,
over 40% of all hospital discharges in 2011 were for people
aged 65 and over, more than twice their share of the
population. However, population ageing alone may be a less
important factor in explaining trends in hospitalisation
rates than changes in medical technologies and clinical
practices. The diffusion of new medical interventions often
g ra d u a l ly ex t e n d s t o o l d e r p o p u la t i o n g ro u p s , a s
interventions become safer and more effective for people at
older ages. But the diffusion of new medical technologies
may also involve a reduction in hospitalisation if it involves
a shift from procedures requiring overnight stays in
hospitals to same-day procedures. In the group of countries
where discharge rates have decreased since 2000, there has
been a strong rise in the number of day surgeries (Kumar
and Schoenstein, 2013; see also Indicator 3.9 for evidence
on the rise in day surgeries for cataracts).
Hospital discharge rates vary not only across countries,
but also within countries. In several European countries (e.g.,
Fi n l a n d , G e r m a ny, I t a ly, Po r t u g a l , S p a i n a n d t h e
United Kingdom), hospital medical admissions (excluding
admissions for surgical interventions) vary by more than twofold across different regions in the country (OECD, 2014).
72
In general across EU countries, the main conditions

leading to hospitalisation in 2012 were circulatory diseases,
pregnancy and childbirth, injuries and other external
causes, diseases of the digestive system, respiratory
diseases and cancers.
Lithuania had the highest discharge rate for circulatory
diseases in 2012, followed by Bulgaria, Germany and
Austria (Figure 3.6.2). The high rates in Bulgaria and
Lithuania are associated with many people having heart
attack and other circulatory diseases (see Indicator 1.4).
This is not the case in Germany and Austria.
Austria and Germany have the highest discharge rates
for cancer, followed by Hungary (Figure 3.6.3). In Austria,
this high rate is associated with a high rate of hospital
readmissions for further investigation and treatment of
cancer patients (European Commission, 2008).

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). These comprise between 3% and
10% 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, Ireland
and the Netherlands include only acute care/shortstay hospitals.
References
European Commission (2008), Hospital Data Project Phase 2,
Final Report, European Commission, Luxembourg.
Kumar, A. and M. Schoenstein (2013), Managing Hospital
Volumes: Germany and Experiences from OECD Countries, OECD Health Working Papers No. 64, OECD
Publishing, Paris, http://dx.doi.org/10.1787/5k3xwtg2szzr-en.
We Know and What Can Be done to Improve Health System
10.1787/9789264216594-en.
3.6. HOSPITAL DISCHARGES
3.6.1. Hospital discharges per 1 000 population, 2000 and 2012 (or nearest year)
2000
2012
99
133
158
141
157
166
175
113
99
129
119
136
136
149
142
162
152
168
150
163
171
170
173
172
178
173
195
189
200
196
217
200
202
251
243
270
250
267

300
80
100
50
N
S w or w
i t z ay 2
er
la
n
Se d
rb
Tu ia
rk
ey 2
F Y M Ic e
R on l an
of te d
M ne
a c gr
ed o
on
ia 1
Au
st
r
Bu i a 1
lg
Ge ar i a
rm
Li an
th y
u
Ro a n i a
m
C z H a ni a
e un
Sl ch R g a
r
ov
a k epu y
Re bli
pu c
bl
Gr i c 2
ee
ce 1
La
t
Fi via
nl
an
d1
EU
Es 28
to
D e ni a 1
nm
Sl ar k
ov
e
B e ni a
lg
iu
Fr m
an
Sw ce
ed
Po en
la
n
L u Cr d 2
Un xem o a t i
i te bo a
d
K i ur g 1
ng
do
Ir e m
la
nd
M 1
al
ta 1
Ne I
t
th al
er y
la
Po nds
r tu
g
Sp a l
ai
Cy n 1
pr
us 1
1. Excludes discharges of healthy babies born in hospital (between 3-10% of all discharges).
2. Includes same-day discharges.
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; Eurostat Statistics Database, WHO Europe Health for All Database.
1 2 http://dx.doi.org/10.1787/888933155604
3.6.2. Hospital discharges for circulatory diseases

per 1 000 population, 2012 (or nearest year)
Lithuania
Bulgaria
Germany
Austria
Hungary
Estonia
Latvia
Romania
Slovak Republic
Czech Republic
Greece
Finland
Poland
EU28
Sweden
Slovenia
Italy
Denmark
Belgium
Luxembourg
France
Croatia
Netherlands
Malta
United Kingdom
Portugal
Spain
Ireland
Cyprus
49
40
38
37
36
33
31
30
30
29
28
27
26
24
24
21
20
20
20
19
19
18
16
15
14
13
13
11
5
Norway
Switzerland
FYR of Macedonia
Iceland
Turkey
24
14
14
12
15
Austria
Germany
Hungary
Greece
Romania
Estonia
Lithuania
Bulgaria
Croatia
Slovenia
Slovak Republic
Finland
Latvia
EU28
Czech Republic
Luxembourg
Denmark
Sweden
Poland
Italy
France
Belgium
Netherlands
Portugal
United Kingdom
Spain
Malta
Ireland
Cyprus
29
25
23
20
19
19
19
18
18
18
17
17
16
15
15
14
14
13
12
12
12
11
11
11
10
10
9
8
4
Norway
Switzerland
Iceland
FYR of Macedonia
Turkey
18
3.6.3. Hospital discharges for cancers

30
45
60

1 2 http://dx.doi.org/10.1787/888933155604
16
14
12
12
7
10
20
30

1 2 http://dx.doi.org/10.1787/888933155604
73
3.7. AVERAGE LENGTH OF STAY IN HOSPITALS
The average length of stay in hospitals is often regarded

as an indicator of efficiency. All other things being equal, a
shorter stay will 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 cause adverse effects on health outcomes, or reduce
the comfort and recovery of the patient. If this leads to a
greater readmission rate, costs per episode of illness may
fall only slightly, or even rise.
In 2012, the average length of stay in hospitals for all
causes among EU countries was the lowest in Denmark and
Sweden (Figure 3.7.1). It was highest in Finland, the
Czech Republic, Hungary 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 most EU countries, falling from
9.6 days in 2000 to 7.8 days in 2012 on average across
EU member states (Figure 3.7.1). It fell particularly quickly
in some countries that had relatively long stays in 2000
(e.g., in Bulgaria, the Slovak Republic, the United Kingdom
and Switzerland).
Focusing on average length of stay for specific diseases
or conditions can remove some of the effect of different
case mix and severity. Figure 3.7.2 shows that the average
length of stay for a normal delivery in EU countries ranges
from less than two days in the United Kingdom and the
Netherlands, to five days or more in the Slovak Republic,
Romania and Hungary. 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 threeand-a-half days in 2012 on average in EU member states.
The average length of stay following acute myocardial
infarction (AMI or heart attack) was around seven days on
average in EU countries in 2012 (Figure 3.7.3). It was lowest
in Denmark, Bulgaria and Sweden (less than five days), and
highest in Germany (over ten days).
Several factors can explain these cross-country
variations. Differences in the clinical need of patients may
obviously play a role, but these variations also likely reflect
differences in clinical practices and payment systems. The
combination of an abundant supply of beds with the
structure of hospital payments may provide hospitals with
incentives to keep patients longer. A growing number of
countries (e.g., France, Germany, Poland) have moved to
prospective payment methods often based on diagnosisrelated 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. In Switzerland, the move from
p e r d i e m p ay m e n t s t o D R G - b a s e d p ay m e n t s h a s
contributed to the reduction in length of stay in those
74
cantons that have modified their payment system (OECD

and WHO, 2011). In the Netherlands, the introduction of a
new DRG-based system in 2006 is also credited with
contributing to the reduction in average length of stay
(Westert and Klazinga, 2011).
Most countries are seeking to reduce ALOS whilst
maintaining or improving the quality of care. A diverse set
of policy options are available to achieve these twin aims.
Strategic reductions in hospital bed numbers alongside the
development of community care services can shorten
ALOS, such as seen in Denmarks quality-driven reforms of
the hospital sector (OECD, 2013). Other options include
promoting the take-up of less invasive surgical procedures,
changes in hospital payment methods, the expansion of
early discharge programmes which enable patients to
return to their home to receive follow-up care, and support
for hospitals to improve the co-ordination of care across
diagnostic and treatment pathways.

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.
Compared with the 2012 edition of Health at a Glance
Europe, the data cover all inpatient cases (including
not only curative/acute care cases) for most countries,
with the exception of the Netherlands where the data
still refer to curative/acute care only (resulting in an
under-estimation).
Discharges and average length of stay of healthy
babies born in hospitals are excluded in several
countries (e.g., Austria, Cyprus, Estonia, Finland,
Greece, Ireland, Latvia, Luxembourg, Spain), resulting
in a slight over-estimation of average length of stay
compared with other countries.
References
OECD (2013), OECD Reviews of Health Care Quality: Denmark
2013 Raising Standards, OECD Publishing, Paris, http://
dx.doi.org/10.1787/9789264191136-en.
OECD and WHO (2011), OECD Reviews of Health Systems:
Switzerland 2011, OECD Publishing, Paris, http://
dx.doi.org/10.1787/9789264120914-en.
Westert, G. and N. Klazinga (2011), The Dutch Health Care
System, 2011, Report prepared for the Commonwealth
Fund, New York.
3.7. AVERAGE LENGTH OF STAY IN HOSPITALS
3.7.1. Average length of stay in hospital for all causes, 2000 and 2012 (or nearest year)
2000
2012
4.0
4.4
6.2
6.1
6.1
5.9
7.8
8.9
11.2
12.2
8.8
8.7
12.8
5.8
6.2
8.8
12.3
11.5
7.1
5.8
6.4
7.4
6.2
6.6
7.2
7.1
8.4
9.0
10.7
7.2
7.4
7.5
7.5
9.3
10.4
7.5
7.6
8.6
9.0
9.6
7.9
7.8
9.2
7.9
8.0
7.7
8.0
9.8
10.4
11.4
9.1
8.4
9.0
9.4
9.0
8.3
8.4
8.1
11.9
10.7
9.1
11.9
9.2
9.5
8.7
9.5
12
12.6
11.2
11.4
Days
15
Cz
e c F in
h lan
Re d
pu
Hu b l i c
ng
Ge ar y
rm
a
Cr n y
oa
ti
Lu Fr a a
xe n c
m e
bo
P o ur g
r tu
ga
La l
tv
Be ia
lg
L i ium
th
ua
ni
a
It a
Au l y
st
Es ria
to
ni
a
EU
Sl
28
ov
a k Sp
Re a in
pu
Sl blic
ov
Ro e n i a
m
an
Un
i te C y ia
d pr
K i us
ng
do
m
M
al
Po t a
la
n
N e Gr d
th eec
er e
la
nd
Ir e s 1
la
Bu nd
lg
a
Sw ria
ed
De en
nm
ar
k
Sw
it z
e
FY
rla
R
n
of S d
M er b
ac ia
M e do
on n
te ia
ne
g
No ro
rw
Ic a y
el
an
Tu d
rk
ey
1. Data refer to average length of stay for curative (acute) care only (resulting in an under-estimation).
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; Eurostat Statistics Database, WHO Europe Health for All Database.
1 2 http://dx.doi.org/10.1787/888933155611
3.7.2. Average length of stay for normal delivery, 2012

(or nearest year)
Slovak Republic
Romania
Hungary
Croatia
Cyprus
Czech Republic
Bulgaria
France
Luxembourg
Belgium
Greece
Austria
Poland
Slovenia
Latvia
Lithuania
EU27
Italy
Finland
Germany
Denmark
Portugal
Malta
Spain
Sweden
Ireland
Netherlands
United Kingdom
Germany
Croatia
Estonia
Lithuania
Austria
Malta
Portugal
Hungary
Italy
United Kingdom
Finland
Spain
Slovenia
Luxembourg
Romania
Belgium
EU28
Greece
Ireland
Latvia
Czech Republic
Cyprus
Poland
France
Netherlands
Slovak Republic
Sweden
Bulgaria
Denmark
5.1
5.0
5.0
4.9
4.6
4.4
4.2
4.2
4.1
4.0
4.0
3.9
3.9
3.9
3.6
3.6
3.6
3.4
3.1
3.0
2.7
2.7
2.4
2.4
2.3
2.0
1.9
1.5
FYR of Macedonia
Switzerland
Norway
Iceland
Turkey
4.7
3.1
1.8
1.3
6
Days

1 2 http://dx.doi.org/10.1787/888933155611
10.3
9.5
9.5
9.5
8.0
8.0
7.9
7.9
7.8
7.6
7.5
7.4
7.3
7.2
7.1
7.1
7.1
7.0
6.9
6.7
6.3
6.2
6.2
6.1
5.6
4.9
4.7
4.3
3.9
Switzerland
FYR of Macedonia
Iceland
Turkey
Norway
3.6
3.7.3. Average length of stay for acute myocardial

infarction (AMI), 2012 (or nearest year)
7.3
7.1
6.8
4.6
4.0
12
Days

1 2 http://dx.doi.org/10.1787/888933155611
75
3.8. CARDIAC PROCEDURES
Heart diseases are a leading cause of hospitalisation and

death in European countries (see Indicator 1.4). Coronary
artery bypass graft and angioplasty have revolutionised the
treatment of ischemic heart diseases in the past few
decades. A coronary bypass is an open-chest surgery
involving the grafting of veins and/or arteries to bypass one
or multiple obstructed arteries. A coronary angioplasty is a
much less invasive procedure involving the threading of a
catheter with a balloon attached to the tip through the
arterial system to distend the coronary artery at the point of
obstruction; the placement of a stent to keep the artery
open accompanies the majority of angioplasties.
In 2012, Germany, Hungary, the Netherlands, Belgium
and Austria had the highest rates of revascularisation
procedures overall and coronary angioplasty more
specifically (Figure 3.8.1).
A number of reasons can explain cross-country
variations in the rate of coronary bypass and angioplasty,
including: i) differences in the capacity to deliver and pay
for these procedures; ii) differences in clinical treatment
guidelines and practices; and iii) differences in coding and
reporting practices.
However, the large variations in the number of
revascularisation procedures across countries do not seem
to be closely related to the incidence of ischemic heart
d i s e a s e ( I H D ) , a s m e a s u re d by I H D m o r t a l i t y ( s e e
Indicator 1.3). For example, IHD mortality in Germany is
below the EU average, but Germany has the highest rate of
revascularisation procedures.
National averages can hide important variations in
utilisation rates within countries. For example, in Germany,
the rate of coronary bypass surgery and angioplasty is
nearly three times higher in certain regions compared with
others. There are also wide variations in the use of these
revascularisation procedures across regions in other
countries such as Finland, France and Italy (OECD, 2014).
The use of angioplasty has increased rapidly over the
past 20 years 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. On average across
EU countries, angioplasty now accounts for 80% of all
revascularisation procedures (Figure 4.6.2), and exceeds
85% in Estonia, France and Spain. In Denmark, the share of
angioplasty increased quickly between 2000 and 2006, but
has fallen slightly since then. This slight reduction may be
due partly to the fact that the data reported by Denmark
does not cover the growing number of angioplasties that
are performed as day cases (without any overnight stay in
76
hospital). In addition, in Denmark as in other countries, the

greater use of drug-eluting stents reduces the likelihood
that the same patient will need another angioplasty.
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 5 600 in 2011 compared with EUR 13 800 for a
coronary bypass (Koechlin et al., 2014). 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.

The data for most countries cover both inpatient
and day cases, with the exception of Denmark,
Iceland, Norway, Portugal and Switzerland, where
they only include inpatient cases (resulting in some
u n d e r- e s t i m a t i o n in t h e nu m b e r o f c o ro n a ry
angioplasties; this limitation in data coverage does
not affect the number of coronary bypasses since
nearly all patients are staying at least one night in
hospital after such an operation). Some of the
variations across countries may also be due to the use
of different classification systems and different codes
for reporting these two procedures.
In Ireland and the United Kingdom, the data only
include activities in publicly-funded hospitals,
resulting in an under-estimation (it is estimated that
approximately 15% of all hospital activity in Ireland is
undertaken in private hospitals). Data for Portugal
relate only to public hospitals on the mainland. Data
for Spain only partially include activities in private
hospitals.
References
Koechlin, F. et al. (2014), Comparing Hospital and Health
Prices and Volumes Internationally: Results of a Eurostat/
OECD Project, OECD Health Working Papers, No. 75, OECD
Publishing, Paris, http://dx.doi.org/10.1787/5jxznwrj32mp-en.
Performance?, OECD Health Policy Studies, OECD Publishing, Paris, http://dx.doi.org/10.1787/9789264216594-en.
3.8. CARDIAC PROCEDURES
3.8.1. Coronary revascularisation procedures, 2012 (or nearest year)

Coronary angioplasty
Coronary bypass

500
430
400
325
296
300
293
282
274
263
277
261
249
244
241
236
256
236
235
231
230
227
244
215
233
191
200
181
159
152
136
128
105
100
Un
Ic
Ro
No
rw
ay
el
S
FY
w i and
t
R
o f z er l
a
M
ac nd
ed
on
ia
Tu
rk
ey
ia
an
nd
ai
la
Sp
Ir e
ga
do
r tu
i te
Lu
Ki
Po
ng
nd
la
an
Po
nl
Fi
Sl
ov
en
ur
ia
en
bo
m
xe
23
Sw
EU
ed
ce
tia
an
oa
Cr
De
Cz
ec
Ne
Fr
ly
ar
It a
nm
ta
ni
al
to
Es
ic
ni
bl
Re
pu
ua
th
Li
Be
Au
st
iu
lg
ria
y
th
er
la
nd
ar
an
ng
Hu
rm
Ge
Note: Some of the variations across countries are due to different classification systems and recording practices.
1 2 http://dx.doi.org/10.1787/888933155625
3.8.2. Coronary angioplasty as a share of total revascularisation procedures, 2000 to 2012 (or nearest year)
2000
%
90
87
88
86
85
84
84
84
2006
82
82
2012
83
81
81
80
81
80
77
77
78
77
75
75
72
72
70
67
50
ay
an
la
el
Ic
nd
No
er
Sw
it z
rw
k
ar
nm
la
nd
De
Po
y
ar
ng
Hu
Po
r tu
ga
m
iu
lg
Be
do
d
ng
nl
Un
i te
Ki
Fi
la
an
s
nd
20
er
th
Ne
g
ur
bo
m
xe
Lu
EU
nd
la
ic
bl
Re
h
Cz
ec
Ir e
pu
al
ta
ia
M
Sl
ov
en
en
ed
Sw
Ge
rm
an
ly
It a
ria
n
ai
st
Au
Sp
an
Fr
Es
to
ni
ce
30
Note: Revascularisation procedures include coronary bypass and angioplasty.

Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en.
1 2 http://dx.doi.org/10.1787/888933155625
77
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 interventions.
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 Nordic countries, 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, although there may be some
exceptions (e.g., people requiring general anesthesia or
with severe comorbidities) (Lundstrm 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, Hungary 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 since
2000, such as in Portugal and Austria (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 2012 (Figure 3.9.1). In
France, this share also increased from 32% in 2000 to 85%
in 2012. 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 two-thirds of all cataract surgeries.
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% versus 40%), because it is related to age and
women live longer (Lundstrm et al., 2012).
In Sweden, there is evidence that cataract surgeries are
now being performed on patients suffering from less severe
78
vision problems compared to a decade 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
(Lundstrm 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 (in-patient
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, Estonia,
Finland, France, Luxembourg, the United Kingdom
where these cases are included. Caution is therefore
required in making cross-country comparisons, given
the incomplete coverage of same-day surgeries in
several countries.
In Ireland 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 approximately 15% of all
hospital activity is undertaken in private hospitals).
Data for Portugal relate only to public hospitals on the
mainland. Data for Spain only partially include
activities in private hospitals.
References
Castoro, C. et al. (2007), Policy Brief Day Surgery: Making it
Happen, World Health Organization on Behalf of the
European Observatory on Health Systems and Policies,
Copenhagen.
Lundstrm, M. et al. (2012), Evidence-based Guidelines for
Cataract Surgery: Guidelines Based on Data in the European Registry of Quality Outcomes for Cataract and
Refractive Surgery Database, Journal of Cataract and
Refractive Surgery, Vol. 38, No. 6, pp. 1086-1093, June.
Swedish Association of Local Authorities and Regions and
National Board of Health and Welfare (2010), Quality and
Efficiency in Swedish Health Care Regional Comparisons
2009, Stockholm.
3.9. CATARACT SURGERIES
3.9.1. Share of cataract surgeries carried out as day cases, 2000 and 2012 (or nearest year)
53.3
50.9
19.4
26.3
25.4
37.1
26.4
31.6
31.9
40
41.2
46.7
52.1
60
56.8
68.3
80
77.2
93.6
87.3
96.8
78.6
81.4
91.3
84.7
2012
91.9
93.7
94.4
85.9
97.2
97.3
98.0
93.0
98.2
83.1
98.4
81.6
98.7
d1
99.7
82.8
98.8
2000
%
100
1.2
9.3
20
ia
on
ed
of
Sw
ac
it z
er
Tu
r
ke
nd
la
an
ay
el
rw
No
th
Li
Ic
a
ua
ni
nd
la
Po
ng
ar
ic
bl
pu
Hu
ov
Lu
ak
Re
Au
st
ria
g1
bo
ur
20
xe
Fr
EU
ly
an
It a
ce
nd
la
Ir e
Po
r tu
ga
ic 1
FY
Sl
Un
Cz
i te
ec
Re
pu
lg
bl
iu
ai
Sl
Be
ov
Sp
en
ia 1
en
m1
Ki
ng
Sw
ed
do
ar
nm
nl
an
De
Fi
er
Ne
th
Es
to
la
ni
nd
a1
1. Data include outpatient cases in hospitals and outside hospitals.

1 2 http://dx.doi.org/10.1787/888933155636
3.9.2. Growth in cataract surgeries per capita, day cases and inpatient cases, 2000 to 2012 (or nearest year)
Day cases
Inpatient cases
44.8
54.2
Average annual growth rate (%)

60
-0.5
2.6
3.0
-10.8
-13.2
-20.0
-17.3
-15.0
-3.8
-0.1
-20.0
-13.6
-16.1
-18.4
-20
-13.4
-4.3
-8.6
-8.5
-1.8
5.1
5.2
6.2
6.7
7.4
8.7
9.3
5.8
9.6
12.4
20
5.7
33.1
40
ay
rw
la
er
it z
Sw
No
nd
ly
It a
d
an
nl
do
ng
Ki
d
Fi
m
iu
lg
i te
Un
en
ed
Sw
Be
s
er
th
Ne
nm
De
la
ar
nd
n
ai
Sp
nd
la
ur
bo
m
xe
Lu
Ir e
g1
a1
ni
to
Es
ce
an
Fr
nd
la
Po
ria
st
Au
Po
r tu
ga
-40
1. Data include outpatient cases in hospitals and outside hospitals.

1 2 http://dx.doi.org/10.1787/888933155636
79
3.10. HIP AND KNEE REPLACEMENT
Significant advances 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.
Ostheoarthritis is one of the ten most disabling diseases
in developed countries. Worldwide estimates are that 10%
of men and 18% of women aged over 60 years have
symptomatic osteoarthritis, including moderate and severe
forms (WHO, 2014). 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
(European Commission, 2008). While joint replacement
surgery is mainly carried out among people aged 60 and over,
it can also be performed among people at younger ages.
In 2012, Germany, Austria, Sweden, Finland and
Belgium had the highest rates of hip replacement among
EU countries. Hip replacement rates were also very high in
Switzerland (Figure 3.10.1). These countries were also those
that had the highest rates of knee replacement (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 chang e significantly after ag e standardisation
(McPherson et al., 2013; OECD, 2014).
hip replacement on average across European countries was

about EUR 6 800, while the price of a knee replacement was
EUR 6 300 (Koechlin et al., 2014).

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
also be performed for other knee diseases such as
rheumatoid arthritis.
Classification systems and registration practices
v a r y a c r o s s c o u n t r i e s w h i ch m ay a f f e c t t h e
comparability of the data. Some countries only
include total hip replacement (e.g., Estonia) while
most also include partial replacement. In Ireland and
the United Kingdom, the data only include activities
in publicly-funded hospitals (it is estimated that
approximately 15% of all hospital activity is undertaken
in private hospitals). The data for Portugal relate only
to public hospitals on the mainland. The data for
Spain only partially include activities in private
hospitals.
National averages can mask important variations in hip

and knee replacement rates within countries. In Germany,
France and Italy, the rate of knee replacement is more than
two times higher in certain regions compared with others,
even after age-standardisation (OECD, 2014).
References
The number of hip and knee replacements has

increased in recent years in most European countries, with
knee replacements generally growing more rapidly,
although the volume of knee replacements still remains
below that of hip replacements (Figures 3.10.3 and 3.10.4).
I n D e n m a r k , t h e nu m b e r o f h i p rep l a c e m e n t p e r
100 000 population increased by 40% between 2000 and
2012, while the knee replacement rate more than tripled,
although the rates have been stable or declined slightly in
recent years. The growth rate for both interventions was
lower in France, but still the hip replacement rate increased
by more than 10% while the knee replacement rate rose by
80% between 2000 and 2012.
Koechlin, F. et al. (2014), Comparing Hospital and Health

Prices and Volumes Internationally: Results of a Eurostat/
OECD Project, OECD Health Working Papers, No. 75, OECD
Publishing, Paris, http://dx.doi.org/10.1787/5jxznwrj32mp-en.
The growing volume of hip and knee replacement is

contributing to health expenditure growth since these are
expensive interventions. In 2011, the estimated price of a
80
European Commission (2008), Major and Chronic Diseases

Report 2007, EC Directorate-General for Health and Consumers, Luxembourg.
McPherson, K., G. Gon and M. Scott (2013), International

Variations in a Selected Number of Surgical Procedures,
OECD Health Working Papers, No. 61, OECD Publishing,
Paris, http://dx.doi.org/10.1787/5k49h4p5g9mw-en.
10.1787/9789264216594-en.
WHO (2014), Chronic Rheumatic Conditions, Fact Sheet,
WHO, Geneva, available at: www.who.int/chp/topics/rheumatic/en/.
3.10. HIP AND KNEE REPLACEMENT
3.10.1. Hip replacement surgery, per 100 000 population,

Germany
Austria
Sweden
Finland
Belgium
France
Denmark
Luxembourg
Netherlands
Slovenia
United Kingdom
Greece
Czech Republic
Italy
EU27
Hungary
Croatia
Lithuania
Ireland
Latvia
Spain
Slovak Republic
Estonia
Portugal
Poland
Malta
Romania
Cyprus
287
272
242
237
237
230
227
217
216
189
177
168
167
164
157
137
135
127
118
105
102
95
92
88
78
77
53
15
Switzerland
Norway
Iceland
3.10.2. Knee replacement surgery,

Austria
Finland
Germany
Belgium
Luxembourg
Denmark
Malta
Sweden
United Kingdom
France
Netherlands
Czech Republic
EU24
Slovenia
Spain
Italy
Lithuania
Portugal
Hungary
Cyprus
Croatia
Ireland
Latvia
Poland
Romania
173
100
206
184
173
171
162
140
139
139
118
116
113
112
105
104
68
62
59
53
48
47
46
24
17
Switzerland
Norway
Iceland
292
250
217
206
200
300
176
132
90
100
200
300

1 2 http://dx.doi.org/10.1787/888933155643

1 2 http://dx.doi.org/10.1787/888933155643
3.10.3. Trend in hip replacement surgery, 2000-12,

selected countries
3.10.4. Trend in knee replacement surgery, 2000-12,

selected countries
Denmark
France
Germany
Austria
Denmark
France
Poland
United Kingdom
EU27
Germany
United Kingdom
EU24

300

300
250
250
200
200
150
150
100
100
50
50
0
2000
2002
2004
2006
2008
2010
2012

1 2 http://dx.doi.org/10.1787/888933155643
2000
2002
2004
2006
2008
2010
2012

1 2 http://dx.doi.org/10.1787/888933155643
81
3.11. PHARMACEUTICAL CONSUMPTION
Growth in pharmaceutical spending slowed down or was

negative in many European countries in recent years, due
mainly to price reductions and a growing share of the generic
market (see Indicator 6.4 Pharmaceutical expenditure).
However, the overall quantities of pharmaceuticals consumed
have often continued to increase, partly driven by growing
demand for drugs to treat ageing-related and chronic
diseases.
This section discusses the volume of consumption of
four categories of pharmaceut icals: drugs ag ainst
hypertension, cholesterol-lowering drugs, antidiabetics and
antidepressants. Consumption of these drugs is measured
through the defined daily dose (DDD) unit (see the box on
Definition and comparability).
Hypertension is an important public health problem. It
has been estimated that one in three adults worldwide is
affected by hypertension, and 13% of mortality is associated
with high blood pressure (WHO, 2012). The consumption of
antihypertensive medications has nearly doubled on average
in EU countries between 2000 and 2012 (Figure 3.11.1).
In 2012, consumption per capita was the highest in
Germany, Hungary and the Czech Republic.
The use of cholesterol-lowering drugs has more than
tripled across EU countries from fewer than 29 DDDs per
1 000 people per day in 2000 to nearly 100 DDDs in 2012
(Figure 3.11.2). Both the epidemiological context for
instance, growing obesity and increased screening and
treatment explain the very rapid growth in the consumption
of cholesterol-lowering medications. The United Kingdom,
t h e S lova k R ep u bl ic a n d B e l g iu m h a d t h e h i gh e s t
consumption per capita in 2012, with levels that were at
least 30% higher than the EU average. While these crosscountry differences may partly reflect differences in the
prevalence of cholesterol levels in the population,
differences in clinical guidelines for the control of bad
cholesterol also play a role.
The use of drugs against diabetes has nearly doubled on
average across EU countries between 2000 and 2012
(Figure 3.11.3). This growth can be explained by a rising
prevalence of diabetes, largely linked to increases in the
prevalence of obesity. In 2012, the consumption of
antidiabetics was highest in Finland, Germany and the
United Kingdom. While the consumption of antidiabetics in
Finland and Germany was about the same as in France
in 2000, it has increased much more rapidly since then.
In 2012, more than 20% of men aged 65 and over in Finland
took at least one drug against diabetes, compared with 14%
in Denmark and 15% in Sweden (NOMESCO, 2013).
The consumption of antidepressants has also nearly
doubled in EU countries since 2000 (Figure 3.11.4). Guidelines
for the pharmaceutical treatment of depression vary across
countries, and there is also great variation in prescribing
behaviors among general practitioners and psychiatrists
across and within countries. Iceland had the highest level of
consumption of antidepressants in 2012, almost two-times
greater than in Norway. Nearly 30% of women aged 65 and
over took at least one type of antidepressants in Iceland
in 2012, compared with less than 15% in Norway (NOMESCO,
2013). Among EU countries, antidepressants consumption
in 2012 was highest in Portugal, Denmark and Sweden.
82
Greater intensity and duration of treatments are some of

the factors explaining the general increase in antidepressant
consumption. In addition, rising consumption can also be
explained by the extension of the indications of some
antidepressants to milder forms of depression, generalised
anxiety disorders or social phobia. These extensions have
raised concerns about appropriateness. Changes in the
social acceptability and willingness to seek treatment during
episodes of depression have also contributed to increased
consumption.
Some researchers have suggested that the growing use of
antidepressants may also be linked to the insecurity created
by the economic crisis. In Spain, the consumption of
antidepressants per capita increased by 23% between 2007
and 2012, although this increase was lower than in the
preceding five years (44% between 2002 and 2007). In
Portugal, antidepressant consumption went up by 30%
between 2007 and 2012, but this was also slower than the
60% growth rate between 2002 and 2007. The consumption
of antidepressants in recent years rose even more quickly in
countries such as Germany (a rise of over 50% between 2007
and 2012) which were less affected by the economic crisis.

Defined daily dose (DDD) is the assumed average
maintenance dose per day for a drug used for its main
indication in adults. DDDs are assigned to each active
i n g re d i e n t ( s ) i n a g ive n t h e ra p e u t i c c l a s s 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.
The volume of hypertension drugs consumption
presented in Figure 3.11.1 refers to the sum of
five ATC2 categories which can all be prescribed
against hypertension (antihypertensives, diuretics,
beta-blocking agents, calcium channel blockers and
agents acting on the renin-angiotensin system).
Data generally refer to outpatient consumption only,
except for the Czech Republic, Estonia, Italy and
Sweden where data also include hospital consumption.
The data for Spain refer to outpatient consumption for
prescribed drugs covered by the National Health
System (public insurance).
References
NOMESCO Nordic Medico-Statistical Committee (2013),
Health Statistics for the Nordic Countries, NOMESCO,
Copenhagen.
WHO World Health Organization (2012), World Health
Statistics 2012, WHO, Geneva.
3.11. PHARMACEUTICAL CONSUMPTION
3.11.1. Hypertension drugs consumption, 2000 and 2012

(or nearest year)
3.11.2. Anticholesterols consumption, 2000 and 2012

(or nearest year)
2000
2000
Austria
2012
Estonia
191
Luxembourg
41
Austria
225
Portugal
2012
66
Germany
252
71
France
266
Italy
80
Spain
270
Sweden
80
Netherlands
304
France
92
93
Estonia
329
Spain
Belgium
330
Portugal
95
EU18
357
EU18
97
Sweden
362
Finland
98
Slovak Republic
365
Czech Republic
100
Hungary
102
102
United Kingdom
378
Italy
392
Slovenia
Denmark
395
Netherlands
Slovenia
Finland
Hungary
Germany
127
Slovak Republic
534
567
131
United Kingdom
Iceland
271
Iceland
Norway
278
Norway
100
120
Belgium
442
116
Denmark
421
Czech Republic
107
Luxembourg
411
200
300
400
500
600
Defined daily dose, per 1 000 people per day
134
83
118
30
60
90
120
150

1 2 http://dx.doi.org/10.1787/888933155650

1 2 http://dx.doi.org/10.1787/888933155650
3.11.3. Antidiabetics consumption, 2000 and 2012

(or nearest year)
3.11.4. Antidepressants consumption, 2000 and 2012

(or nearest year)
2000
2000
Austria
2012
Estonia
39
Denmark
21
Hungary
51
27
Sweden
54
Slovak Republic
Estonia
54
Italy
42
Netherlands
42
Slovak Republic
58
2012
30
Portugal
61
Czech Republic
Belgium
62
France
50
Slovenia
51
Luxembourg
63
46
Italy
66
Germany
52
France
66
Luxembourg
52
Spain
66
EU18
EU18
66
Austria
Slovenia
74
Hungary
75
Czech Republic
83
Finland
85
Iceland
49
25
50
75
100

1 2 http://dx.doi.org/10.1787/888933155650
70
75
81
Denmark
83
Portugal
85
Norway
40
Norway
70
Belgium
Sweden
80
Germany
64
Finland
United Kingdom
78
United Kingdom
58
Spain
71
Netherlands
56
57
Iceland
109
30
60
90
120

1 2 http://dx.doi.org/10.1787/888933155650
83

OECD 2014
Chapter 4
Quality of care
4.1. Avoidable hospital admissions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
86
4.2. Prescribing in primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
88
4.3. Mortality following acute myocardial infarction . . . . . . . . . . . . . . . . .
90
4.4. Mortality following stroke. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
92
4.5. Procedural or postoperative complications . . . . . . . . . . . . . . . . . . . . .
94
4.6. Screening, survival and mortality for cervical cancer . . . . . . . . . . . .
96
4.7. Screening, survival and mortality for breast cancer . . . . . . . . . . . . . .
98
4.8. Screening, survival and mortality for colorectal cancer. . . . . . . . . . .
100
4.9. Childhood vaccination programmes . . . . . . . . . . . . . . . . . . . . . . . . . . .
102
4.10. Influenza vaccination for older people . . . . . . . . . . . . . . . . . . . . . . . . .
104
85
4.1. AVOIDABLE HOSPITAL ADMISSIONS
Most health systems have developed a primary level of

care whose functions include managing new health
complaints that pose no immediate threat to life, managing
long term conditions and supporting the patient in deciding
when referral to hospital-based services are necessary. A
key aim is to keep people well, by providing a consistent
point of care over the longer term, tailoring and coordinating care for those with multiple health care needs
and supporting the patient in self-education and selfmanagement.
Asthma, chronic obstructive pulmonary disease (COPD)
and diabetes are three widely prevalent long term
conditions. Both asthma and COPD limit the ability to
breathe: asthma symptoms are usually intermittent and
reversible with treatment, whilst COPD is a progressive
disease that almost exclusively affects current or prior
smokers. 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 affects around
64 million worldwide and currently is the fourth leading
cause of death worldwide. In 2010, COPD accounted for
around 3% of total deaths in the European Union (WHO,
2013). Diabetes is a condition in which the bodys ability to
regulate excessive glucose levels in the blood is lost. This
can lead to many complications over the longer term such
as kidney failure or loss of sight; in the shorter term, loss of
consciousness or coma can occur. Globally, around
382 million people have diabetes worldwide and this
prevalence is projected to increase by 55% by 2035. In 2011,
the condition is estimated to have been responsible for 10%
of total adult deaths in Europe (IDF, 2013).
Common to all three conditions is the fact that the
evidence base for effective treatment is well established
and much of it can be delivered at a primary care level. A
high performing primary care system can to a significant
extent, therefore, avoid acute deterioration in people living
with asthma, COPD or diabetes and prevent their admission
to hospital.
Figure 4.1.1 shows that among the EU member states,
asthma accounted for an average of 51 hospital admissions
per 100 000 population in 2011. Asthma-related admissions
in the Slovak Republic and Latvia were more than double
the EU average, whereas Italy, Portugal, Germany, Sweden
and Luxembourg report rates that were less than half the
EU average. As shown in Figure 4.1.2, the average COPDrelated admission rate was 199 per 100 000 population in
EU member states in 2011, nearly four times greater than
for asthma. Ireland and Hungary have the highest
admission rates for COPD. Portugal, Italy, Switzerland and
86
France 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 also play an important
role. Hospital admission rates for uncontrolled diabetes
vary 8-fold, as shown in Figure 4.1.3. Italy, United Kingdom
and Spain have the lowest rates, while Austria and Hungary
report rates nearly double the OECD average.
Examining trends, the majority of countries report a
reduction in admission rates for each of the three
conditions over recent years, which may represent an
improvement in the quality of primary care. Other factors
may also be relevant though, including structural factors
such as the accessibility of primary care. The background
prevalence of disease is not necessarily strongly related to
admission rates. The influence of these factors in
determining primary care quality is described in a series of
country reviews currently being undertaken by OECD,
highlighting, for example, the critical role played by quality
indicators to improve the quality of primary care.
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. The indicator for
diabetes is based on the sum of three indicators:
admissions for short-term and long-term
complications; and for uncontrolled diabetes without
complications.
Rates were age-sex standardised to the 2010 OECD
population aged 15 and over. Differences in coding
practices among countries and the definition of an
admission may affect the comparability of data.
Differences in disease classification systems, for
example between ICD-9-CM and ICD-10-AM, may also
affect data comparability.
References
IDF International Diabetes Federation (2013), Diabetes
Atlas, Sixth edition, IDF, available at www.idf.org/sites/
default/files/EN_6E_Atlas_Full_0.pdf.
To, T. et al. (2012), Global Asthma Prevalence in Adults:
Findings from the Cross-Sectional World Health Survey, BMC Public Health, Vol. 12, pp. 204-211.
WHO World Health Organization (2013), Chronic Obstructive Pulmonary Disease (COPD), Background Paper 6.13,
WHO, Geneva, available at www.who.int/medicines/areas/
priority_medicines/BP6_13COPD.pdf.
4.1. AVOIDABLE HOSPITAL ADMISSIONS
4.1.1. Asthma hospital admission in adults, 2006 and 2011 (or nearest year)
2011
2006
Age-sex standardised rates per 100 000 population
160
120
30
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51
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41
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22
40
73
133
151
80
Note: 95% confidence intervals represented by H.

1 2 http://dx.doi.org/10.1787/888933155669
4.1.2. COPD hospital admission in adults, 2006 and 2011 (or nearest year)
2006
2011

400
95
211
237
320
316
227
217
212
211
202
200
199
194
185
169
162
144
143
112
102
90
71
162
100
365
200
378
300
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1 2 http://dx.doi.org/10.1787/888933155669
4.1.3. Diabetes hospital admission in adults, 2006 and 2011 (or nearest year)
2011
2006
600
500
400

79
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55
70
247
221
217
204
181
176
142
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Fi
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138
135
117
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72
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85
100
336
200
405
300
1 2 http://dx.doi.org/10.1787/888933155669
87
4.2. PRESCRIBING IN PRIMARY CARE
B eyo n d c o n s u m p t i o n a n d ex p e n d i t u re ( s e e
Indicators 3.11 Pharmaceutical consumption and 6.4
Pharmaceutical expenditure), information on prescribing
can be used as an indicator of health care quality. This
section includes an indicator on prescribing in primary
care, in order to develop a more comprehensive picture of
quality in the sector. Two related indicators are shown: the
total volume of antibiotics and the volume of quinolones
and cephalosporins as a proportion of all antibiotics,
prescribed in primary care.
There is a clear correlation between the volume of
antibiotics prescribed at community level and prevalence of
resistant bacterial strains. Infections caused by resistant
microorganisms often fail to respond to conventional
treatment, resulting in prolonged illness, greater risk of
death, and higher costs. Reduced prescribing in primary
care has been associated with reductions in antibiotic
resistance. Hence antibiotics should be prescribed only
where there is an evidence-based need, avoiding use in
mild throat infections, for example, which are nearly
always viral (Cochrane Collaboration, 2013). Whilst an
optimal level of prescribing is difficult to establish,
variations in prescribing volume have been validated as a
marker of health care quality in the primary care setting.
Quinolones and cephalosporins are considered secondline antibiotics in most prescribing guidelines. Their use
should be restricted to ensure availability of effective
second-line therapy should first-line antibiotics fail. Again,
although an optimal level of prescribing of these antibiotics
is difficult to establish, there is widespread evidence that
these antibiotics are prescribed unnecessarily where no
antibiotics or a more standard antibiotic would suffice. Their
volume as a proportion of the total volume of antibiotics
prescribed has also been validated as a marker of quality in
the primary care setting (Adriaenssens et al., 2011).
Figure 4.2.1 shows volumes of antibiotics prescribed in
primary care at national level. Volumes vary more than
three-fold across countries, with the Netherlands and
Estonia reporting the lowest volumes and Greece, Cyprus
and Belgium reporting volumes around 1.5 times the
European Union average. Variation is likely to be explained,
on the supply side, by differences in the regulation,
guidelines and incentives that primary care prescribers are
exposed to and, on the demand side, by cultural differences
in attitudes and expectations regarding the natural history
and optimal treatment of infective illness.
88
Figure 4.2.2 shows the volume of quinolones and

cephalosporins as a proportion of all antibiotics prescribed
in primary care. The ten-fold variation across countries is
much greater than that seen for total antibiotic prescribing
volume; Denmark, Norway, the United Kingdom and
Sweden report the lowest proportions, whilst Romania,
Malta, Cyprus, Germany and Greece report volumes more
than 1.5 times the European Union average. There is
modest association in countries ranking across these two
indicators: Greece and Cyprus report high volumes and the
Nordic countries relatively low volumes, for example.
Germany, Romania and Hungary, however, report low total
prescribing volumes but relatively high proportions of
quinolone and cephalosporin use.
Total use may well exceed the volumes reported here
given that, in some countries, self-medication is common
(Grigoryan et al., 2006). Reducing use is a pressing, yet
complex problem, likely to require multiple co-ordinated
initiatives including surveillance, regulation and education
of professionals and patients. Many such programmes are
underway, including a European Union Joint Programming
Initiative on Antimicrobial Resistance launched in 2008 as
well as a initiatives at national level, such as Belgiums
Antibiotic Policy Coordination Committee, which reported
decreases in antibiotic use and resistance as a result of its
work over the last ten years.

See Indicator 3.11 for a description of the defined
daily dose (DDD). Data generally refer to outpatient
consumption only, except for Iceland, Lithuania, the
Slovak Republic and Cyprus where data also include
use in the hospital sector.
References
Adriaenssens, N. et al. (2011), European Surveillance of
Antimicrobial Consumption (ESAC): Disease Specific
Quality Indicators for Outpatient Antibiotic Prescribing,
Quality and Safety in Health Care, Vol. 20, pp. 764-772.
Cochrane Collaboration (2013), The Cochrane Acute Respiratory Infections Group, available at www.ari.cochrane.org.
Grigoryan, L et al. (2006), Self-medication with Antimicrobial Drugs in Europe, Emerging Infectious Diseases,
Vol. 12, No. 3, pp. 452-459.
4.2. PRESCRIBING IN PRIMARY CARE
4.2.1. Overall volume of antibiotics prescribed, 2011
29.0
28.7
22.3
23.8
23.4
23.2
22.6
21.9
20.4
20.1
19.5
19.0
18.8
18.5
16.5
14.7
14.5
14.4
14.3
14.1
13.0
12.8
11.4
15
12.1
20
17.4
25
20.9
30
27.6
27.6
35
32.0
35.1
DDDs per 1 000 population, per day

40
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lg
ar
i
Fi a
nl
an
d
EU
27
Sp
ai
n2
Po
la
nd
Ir e
la
Po nd
r tu
ga
Sl
l
ov
ak Ma
l
Re t a
pu
bl
ic 1
Lu
It a
xe
m ly
bo
ur
g
Fr
an
ce
Be
lg
iu
Cy m
pr
us 1
Gr
ee
ce
a
ni
to
Ne
th
er
Es
la
nd
1. Data include the hospital sector.

2. Reimbursement data, i.e. not including consumption without a prescription and other non-reimbursed.
Source: ECDC (2013), Surveillance of Antimicrobial Consumption in Europe 2011.
1 2 http://dx.doi.org/10.1787/888933155679
4.2.2. Cephalosporins and quinolones as a proportion of all antibiotics prescribed, 2011
21.7
19.6
18.6
18.5
17.4
15.3
14.9
14.5
14.1
13.2
32.5
29.8
29.1
26.9
25.1
7.6
9.7
9.3
23.9
4.2
4.0
4.3
7.0
10
7.9
15
11.7
20
16.4
25
20.7
30
25.9
35
30.9
37.7
%
40
d1
ay
an
rw
el
Ic
No
S m
e N we
e t den
he
rla
nd
Ir e s
la
nd
Sl
ov
en
ia
La
t
v
L
Cz ith ia
ec ua
n
h
Re i a 1
pu
b
Be lic
lg
iu
m
Es
to
ni
Fr a
an
ce
Fi
nl
an
d
Po
la
n
Po d
r tu
ga
l
EU
27
Sp
ai
n2
Au
st
ria
Lu
It a
xe
m ly
bo
u
Bu r g
lg
ar
Sl
Hu i a
ov
ak nga
Re r y
pu
bl
i
Gr c 1
ee
Ge ce
rm
an
y
Cy
pr
us
M
al
Ro t a
m
an
ia 2
Ki
ng
do
Th
Un
i te
De
nm
ar
1. Data include the hospital sector.

2. Reimbursement data, i.e. not including consumption without a prescription and other non-reimbursed.
Source: ECDC (2013), Surveillance of Antimicrobial Consumption in Europe 2011.
1 2 http://dx.doi.org/10.1787/888933155679
89
4.3. MORTALITY FOLLOWING ACUTE MYOCARDIAL INFARCTION
Mortality due to coronary heart disease has declined

substantially since the 1970s (see Indicator 1.4 Mortality
from heart disease and stroke). This reduction can, in part,
be attributed to better treatments, particularly in the acute
phases of myocardial infarction (AMI). Care for AMI has
changed dramatically in recent decades, with the introduction of coronary care units and treatments aimed at rapidly
restoring coronary blood flow. Clinical practice guidelines,
such as those developed by the European Society of Cardiology, provide clinicians with information on how to optimise
treatments and studies have shown that greater compliance with guidelines improve health outcomes. However,
some AMI patients do not receive recommended care, raising concerns over the quality of care in some countries.
A good indicator of acute care quality is the 30-day AMI
case-fatality rate. This indicator measures the percentage
of people who die within 30-days following admission to
hospital for AMI. The measure reflects the processes of
care, such as timely transport of patients and effective
medical interventions. AMI case-fatality rates have been
used for hospital benchmarking in several countries
including Denmark and the United Kingdom (Kessler and
Geppert, 2005; Cooper et al., 2011). The indicator is
influenced by not only the quality of care provided in
hospitals but also differences in hospital transfers, average
length of stay and AMI severity.
Figure 4.3.1 shows the case-fatality rates within 30 days
of admission for AMI. The panel on the left reports the inhospital case-fatality rate when the death occurs in the
same hospital as the initial AMI admission. The average
age-standardised AMI case-fatality rate across the
European Union was 7.8% in 2011 but rates vary widely
between countries. The lowest age-standardised rates were
in Denmark, Sweden and Norway (with rates at or below
4.5%) and the highest rate in Latvia (14.8%) and Hungary
(13.9%). These cross-country differences relate to several
factors including the quality of pre-hospital emergency
medical services, the diagnosis and treatment patterns
delivered to patients, although some of the variation
between countries may be explained by differences in data
definitions (see box on Definitions and comparability).
Further, better hospital performance in cardiovascular
disease has recently been linked to better quality
governance systems for monitoring and benchmarking
(OECD, forthcoming).
The right-hand-side panel of Figure 4.3.1 shows 30-day
AMI case-fatality rates where fatalities are recorded
regardless of where they occur. This is a more robust
indicator because it records deaths more widely than the
same-hospital indicator, but it requires linked-data which
is not available in all countries. The average AMI casefatality rate was 11.5% in 2011, ranging from 8.2% in Norway
to 18.8% in Hungary. The degree of cross-country variation
is considerably less compared to the same-hospital
indicator. One potential reason for this is that patients may
be more commonly transferred to other facilities in
countries such as Denmark compared to Hungary.
90
Case-fatality rates for AMI have decreased over time,

with almost all countries recording sizeable reductions
between 2001 and 2011 (Figure 4.3.2). The AMI case-fatality
rate for the 18 EU member states reporting data over this
period fell by nearly 40% between 2001 and 2011. Between
2006 and 2011, the rate of decline was particularly striking
in Denmark and the Slovak Republic, where case-fatality
rates fell by more than 35%. These substantial improvements
reflect better and more reliable processes of care, in
particular with respect to rapid re-opening of the occluded
arteries.

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.
population aged 45+ admitted to hospital for AMI.
Standardised rates adjust for differences in age
(45+ years) and sex and facilitate more meaningful
international comparisons.
Data for Turkey only include public hospitals
(excluding university and private hospitals).
References
Cooper, Z. et al. (2011), Does Hospital Competition Save
Lives? Evidence from the English NHS Patient Choice
Reforms, Economic Journal, Vol. 121, pp. F228-F260,
August.
Kessler, D. and J. Geppert (2005), The Effects of Competition
on Variation in the Quality and Cost of Medical Care,
Journal of Economics and Management Strategy, Vol. 14,
No. 3, pp. 575-589.
OECD (forthcoming), Cardiovascular Disease and Diabetes:
Policies for Better Health and Quality of Care, OECD
Publishing, Paris.
4.3. MORTALITY FOLLOWING ACUTE MYOCARDIAL INFARCTION
4.3.1. Case-fatality within 30 days after admission for AMI in adults aged 45 and over, 2011 (or nearest year)
Admission-based (same hospital)
Patient-based (in and out of hospital)

Denmark
3.0
9.6
Sweden
4.5
8.5
Poland
5.2
8.9
Italy
5.8
France
6.2
6.8
Czech Republic
6.8
Ireland
6.8
Netherlands
7.0
Finland
7.0
Slovenia
11.0
9.8
12.6
10.5
7.6
Belgium
7.6
Slovak Republic
7.7
Austria
7.8
EU21/12
7.8
United Kingdom
11.5
10.0
Portugal
8.4
8.5
Spain
8.8
Luxembourg
8.9
Germany
9.0
11.9
Malta
10.1
Hungary
13.9
18.8
Latvia
14.8
Norway
4.5
8.2
5.7
Iceland
5.9
Switzerland
Turkey
10.7
20
15
10
Age-sex standardised rates per 100 admissions
17.0
10
15
20
Age-sex standardised rates per 100 patients

1 2 http://dx.doi.org/10.1787/888933155687
4.3.2. Reduction in admission-based case-fatality within 30 days after admission for AMI in adults aged 45 and over,
2001-11 (or nearest year)
2006
2001
2011

20
15
10
nd
la
er
it z
ay
an
el
Sw
Ic
rw
No
ar
y
an
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Hu
rm
ur
Ge
bo
Lu
xe
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ai
Sp
ga
m
do
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Po
ic
ria
ng
Ki
d
i te
Un
bl
st
Au
pu
Re
ak
ov
18
iu
lg
Be
Sl
d
an
EU
nl
Fi
la
er
th
Ne
Ir e
la
nd
nd
ic
bl
Cz
ec
Re
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an
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ly
Fr
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nd
la
Po
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Sw
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nm
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en

1 2 http://dx.doi.org/10.1787/888933155687
91
4.4. MORTALITY FOLLOWING STROKE
Cerebrovascular disease was the underlying cause for

about 11% of all deaths in EU countries in 2011 (Indicator 1.4
Mortality from heart disease and stroke). Ischemic stroke
represents around 85% of all cerebrovascular disease cases.
It occurs when the blood supply to a part of the brain is
interrupted, leading to a necrosis (i.e. the cells that die) of
the affected part. Treatment for ischemic stroke has
advanced dramatically over the last decade. Clinical trials
have demonstrated clear benefits of thrombolytic treatment for ischemic stroke as well as receiving care in dedicated stroke units to facilitate timely and aggressive
diagnosis and therapy for stroke victims.
Figure 4.4.1 shows the age-sex standardised casefatality rates within 30 days of admission for ischemic
stroke as an indicator of the quality of acute care received
by patients. The left-hand-side panel reports the inhospital case-fatality rate when the death occurs in the
same hospital as the initial stroke admission. The panel on
the right shows the case-fatality rate where deaths are
recorded regardless of whether they occurred in or out of
hospital. The indicator on the right hand side is more
robust because it captures fatalities more comprehensively.
Although more countries can report the more partial samehospital measure, an increasing number of countries are
investing in their data infrastructure and are able to provide
more comprehensive measures.
Based on the measure of deaths in the same hospital,
the standardised case-fatality rate for ischemic stroke was
9.6% on average across EU member states in 2011 but there
were large differences between the highest rate in Latvia
(19.0%) and Malta (18.8%) and the lowest rate in Denmark
(4.1%). There is almost a five-fold cross-country difference
between the highest and lowest percentage of in-hospital
case-fatality for ischemic stroke. System-based factors play
a significant role in explaining these differences. Denmark
for example has been at the forefront of establishing
dedicated stroke units in hospitals, contributing to the
lowest case-fatality rates for ischemic stroke (OECD, 2013).
Patterns of hospital transfers, average length of stay,
emergency retrieval time and average severity of stroke
constitute other factors influencing these rates. One should
note that variation between countries may also, in part, be
explained by differences in data definitions (see box on
Definitions and comparability).
Across the 12 countries that reported in- and out-ofhospital case-fatality rates, 12.7% of patients died within
30-days of being admitted to hospital for stroke. This figure
is higher than the same-hospital based indicator because it
also captures deaths occurring in other hospitals and outof-hospital. Denmark reports age-standardised rate at
10.9% which is above the rates in other Nordic countries
such as Finland, Sweden and Norway. The cross-country
variation is substantially smaller for the in- and out-of-
92
hospital measure compared to the same-hospital measure.

This may be due to systematic differences between
countries in the way that patients are transferred between
hospitals and rehabilitative care facilities following stroke.
Between 2001 and 2011, case-fatality rates for ischemic
stroke declined by over 20% across EU member states
(Figure 4.4.2). These reductions suggest overall improvements
in the quality of care for stroke patients, with gains made in
most countries. However, improvements were not uniform
across countries. Improvements in Belgium and Luxembourg
were below the EU average, while the Czech Republic, the
Netherlands and Norway were able to reduce their case
fatality rates by more than 40% between 2001 and 2011. As in
Denmark, the improvements in case-fatality rates can at least
be partially attributed to the high level of access to dedicated
stroke units in these countries.

In-hospital case-fatality rate following ischemic
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-hospital,
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 unique hospital
admissions and restricted to mortality within the
s a m e h o s p i t a l, s o d if f e re n c e s in p ra c t i c e s 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.
population aged 45+ admitted to hospital for stroke.
Standardised rates adjust for differences in age
(45+ years) and sex and facilitate more meaningful
international comparisons.
Data for Turkey only include public hospitals
(excluding university and private hospitals).
References
OECD (2013), OECD Reviews of Health Care Quality: Denmark
2013 Raising Standards, OECD Publishing, Paris, http://
dx.doi.org/10.1787/9789264191136-en.
4.4. MORTALITY FOLLOWING STROKE
4.4.1. Case-fatality within 30 days after admission for ischemic stroke in adults aged 45 and over, 2011 (or nearest year)
Admission-based (same hospital)
Patient-based (in and out of hospital)

Denmark
4.1
10.9
Finland
5.4
6.0
Austria
6.4
Sweden
6.5
Italy
10.3
9.8
Germany
6.7
Netherlands
7.5
10.3
France
8.5
9.2
Belgium
9.5
Czech Republic
9.6
EU20/11
9.6
Hungary
9.9
Ireland
12.7
13.7
10.2
Spain
10.4
United Kingdom
10.5
Portugal
10.4
10.7
Luxembourg
11.0
Slovak Republic
12.4
12.6
Slovenia
12.8
18.8
Malta
19.0
Latvia
14.8
22.4
Norway
5.3
8.8
Switzerland
7.0
Iceland
7.4
Turkey
11.8
25
20
15
10
12.4
10
15
20
25
Age-sex standardised rates per 100 patients

1 2 http://dx.doi.org/10.1787/888933155692
4.4.2. Reduction in admission-based case-fatality within 30 days after admission for ischemic stroke
in adults aged 45 and over, 2001-11 (or nearest year)
2006
2001
2011

20
15
10
nd
an
el
Ic
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la
rw
it z
Sw
No
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pu
Sl
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ak
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g
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ai
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Sp
nd
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ar
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ic
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bl
pu
iu
Re
ec
Hu
ce
lg
Be
17
an
Fr
EU
Cz
Ne
th
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la
nd
an
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Fi
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1 2 http://dx.doi.org/10.1787/888933155692
93
4.5. PROCEDURAL OR POSTOPERATIVE COMPLICATIONS
Patient safety remains one of the most prominent issues

in healt h po licy and public d ebate. The Europ ean
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 (European Commission, 2008). The
European Union Network for Patient Safety and Quality of
Care, PaSQ Joint Action, was launched in 2012 to create a
permanent platform for future co-operation between
member states in the area of patient safety and quality
of care.
Figures 4.5.1 and 4.5.2 show rates of two adverse events:
post-operative pulmonary embolism (PE) or deep vein
thrombosis (DVT) and post-operative sepsis. PE or DVT
cause unnecessary pain and in some cases death, but can
be prevented by anticoagulants and other measures before,
during and after surgery. Likewise, sepsis after surgery,
which may lead to organ failure and death, can in many
cases be prevented by prophylactic antibiotics, sterile
surg ical techniques and good post-operative care.
Figure 4.5.3 illustrates a sentinel event rates of foreign
body left in during procedure. The most common risk
factors for this never event are emergencies, unplanned
changes in procedure, patient obesity and changes in the
surgical team. Preventive measures include counting
instruments, methodical wound exploration and effective
communication among the surgical team.
Variation in post-operative PE or DVT rates (including all
surgeries) varies more than 10-fold (Figure 4.5.1). Belgium,
Portugal and Spain report the lowest rates, whilst Slovenia
reports rates double the EU average. Rates following hip and
knee replacement surgery are also shown. These are high
risk procedures and higher rates would be expected, yet
this pattern is observed in relatively few countries. Several
explanations are possible, including more careful care after
hip and knee surgery, differences in emergency/elective
case mix across countries, in the mix of procedures across
the public and private sectors if countries vary in the
volume of hip and knee replacements undertaken in each
s e c t o r, i n h ow n a t io n a l d a t ab a s e s li n k s e c o n d a ry
complications back to the primary procedure, or in how
secondary complications are reported to the national
database, across surgical specialities within a country.
Variation in post-operative sepsis (including all
surgeries) is also substantial, at around 5-fold (Figure 4.5.2).
Rates following abdominal surgery, a high risk procedure,
are higher, as expected, in almost all countries.
Variation in rates for the foreign body left in procedure
is around 20-fold (Figure 4.5.3). Belgium, Denmark and
Poland report the lowest rates and Switzerland and Portugal
the highest rates. There is modest correlation in countries
relative performance across the three indicators, with
Belgium and Poland reporting consistently lower rates
compared to other countries.
94
Caution is needed in interpreting the extent to which

these indicators accurately reflect international differences
in patient safety rather than differences in the way that
countries report, code and calculate rates of adverse events
(see box on Definitions and comparability). In some cases,
higher adverse event rates may signal more developed
patient safety monitoring systems rather than worse care.

Surgical 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 for patients aged 15 and older. The rates
have been adjusted by the average number of
secondary diagnoses in order to improve crosscountry comparability. Despite this adjustment, the
results for three countries (Finland, Poland and Italy)
that are reporting less than 1.5 diagnoses per record
may be underestimated. Rates have not been age-sex
standardised, since analyses find that this makes a
marginal difference to countries reported rate or
ranking relative to other countries.
A f u n d a m e n t a l ch a l l e n g e i n i n t e r n a t i o n a l
comparison of patient safety indicators centres on the
quality of the underlying data. The indicators are
typically derived from administrative databases,
rather than systems specifically designed to monitor
adverse events, hence differences in how countries
record diagnoses and procedures and define hospital
episodes can affect calculation of rates. Countries
which rely on clinicians to report adverse events may
record them less completely than countries which
employ specially trained administrative staff to
identify and code adverse events from patients
clinical records, for example. The extent to which
national databases facilitate recording of secondary
diagnoses or to which payments are determined by
diagnosis or procedure lists may also influence
recording. Differences in the use of a present on
admission flag for diagnoses, and differences in
disease classifications systems (for example between
ICD-9-CM and ICD-10-AM) are also known to affect
data comparability. Hence, differences in indicator
rates are likely to reflect differences in coding and
recording practices across countries to some extent,
as well as true differences in the quality of care.
References
European Commission (2008), Communication and Recommendation on Patient Safety, including the Prevention and Control
of Healthcare-Associated Infections Summary of the Impact
Assessment, European Commission, Brussels.
4.5. PROCEDURAL OR POSTOPERATIVE COMPLICATIONS
4.5.2. Postoperative sepsis in adults, 2011

(or nearest year)
4.5.1. Postoperative pulmonary embolism or deep vein

thrombosis in adults, 2011 (or nearest year)
Hip and knee replacement
Abdominal surgeries
All surgeries
356
Belgium
136
Portugal
Spain
268
307
Italy1
Poland1
278
315
Finland1
668
Germany
90
416
432
246
354
554
454
n.a.
802
Slovenia
3 027
1 026
2 749
1 121
1 460
1 427
2 995
Ireland
1 144
452
500
1 667
998
Switzerland
367
350
1 831
Norway
701
964
Sweden
865
Norway
2 356
946
n.a.
Portugal
812
Switzerland
1 736
864
Spain
783
France
758
716
France
768
United Kingdom
1 380
696
Slovenia
591
Ireland
787
657
EU13
557
Sweden
1 182
627
United Kingdom
385
Finland1
1 791
603
Denmark
426
EU13
1 207
413
Germany
421
Italy1
366
Belgium
264
Denmark
1 135
Poland1
107
732
500
1 000
1 500
2000
Adjusted rates per 100 000 surgical discharges
All surgeries
1 000
2 000
3 000
4 000
Adjusted rates per 100 000 surgical discharges
1. The average number of secondary diagnoses is < 1.5.

1 2 http://dx.doi.org/10.1787/888933155709

1 2 http://dx.doi.org/10.1787/888933155709
4.5.3. Foreign body left in during procedure in adults, 2011 (or nearest year)
Adjusted rates per 100 000 medical and surgical discharges
12
11.6
6.5
6.2
5.5
3.5
4.6
4.3
3.9
3.8
6.0
5.5
2.9
2.5
1.9
1.6
0.5
nd
la
er
it z
Sw
No
rw
ay
l
ga
r tu
Po
Fr
an
ce
y
an
rm
ng
i te
Ki
Sw
Un
Ge
do
en
ed
n
ai
Sp
d1
an
nl
Fi
13
EU
ly
It a
ia
en
ov
Sl
nd
la
Ir e
nd
la
Po
ar
nm
De
Be
lg
iu
Note: Some of the variations across countries are due to different classification systems and recording practices.
1 2 http://dx.doi.org/10.1787/888933155709
95
4.6. SCREENING, SURVIVAL AND MORTALITY FOR CERVICAL CANCER
Cervical cancer is highly preventable if precancerous

changes are detected and treated before progression occurs.
The main cause of cervical cancer, which accounts for
approximately 95% of all cases, is sexual exposure to the
human papilloma virus (HPV). In 2012, 34 000 new cervical
cancers are diagnosed in Europe (IARC, 2012). The 2014-16
Comprehensive Cancer Control Joint Action has the
objectives to identify key elements and quality standards for
cancer control in Europe in order to reduce incidence by 15%
by 2020. Countries follow different policies with regards to
the prevention and early diagnosis of cervical cancer. About
half of EU countries have cervical cancer screening organised
through population-based programmes but the periodicity
and target groups vary.
Figure 4.6.1 shows cervical screening rates across
European countries around the years 2002 and 2012 for
women aged 20-69 years. In 2012 (or nearest year), Austria,
Latvia, Germany, Sweden, 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 France, Switzerland, Finland, Iceland, Luxembourg,
Norway, the Netherlands, the Slovak Republic and the
United Kingdom witnessed a decline in screening rates
between 2002 and 2012. A regional pilot screening program
was implemented in Ireland in 2002, so that cervical screening
rates are not comparable between 2002 and 2012.
Cancer survival is one of the key measures of the
effectiveness of cancer care systems, taking into account both
early detection of the disease and the effectiveness of
treatment. Figure 4.6.2 shows a small gain in five-year
cervical cancer survival in the European Union between 19972002 and 2007-12, although gains were not uniform across
countries. Of the ten EU member states reporting data in both
periods, seven recorded modest gains in survival whereas
three countries (Ireland, Finland and Malta) reported a small
decline, although the reduction was not statistically
significant. Among EU member states, Austria reported the
highest rates as well as the highest gain in cervical cancer
survival (although not statistically significant), with 67.9% of
patients surviving five years after diagnosis.
Mortality rates reflect the effect of cancer care over the
past years and the impact of screening, as well as changes
in incidence (OECD, 2013). The mortality rates for cervical
cancer declined in most European countries between 2000
and 2011, apart from Luxembourg, Greece, Croatia, Estonia,
Bulgaria and Latvia (Figure 4.6.3). For some countries such
as Lithuania and Romania, mortality rates remain well
above the EU average. In Ireland, the increase in agestandardised mortality rates from cervical cancer between
2000 and 2011 is not statistically significant.
Since the development of a vaccine against some HPV
types, vaccination programmes have been implemented in
most EU countries (ECDC, 2012), although there is an
ongoing debate about the impact of the vaccine on cervical
cancer screening strategies. By May 2012, 17 of the then
27 EU member states had implemented routine HPV
vaccination programmes. In most cases, the vaccination
96
programmes are financed by national health systems but in

some countries including for example Belgium and France,
recipients contribute to 25% and 35% of the payment,
respectively.

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 countrys
specific policy. Some countries ascertain screening
based on surveys and others based on encounter data,
which may influence the results. Screening rates
reported by member states are calculated from Health
I nt e r v i ew S u r veys o n s e l f- p e rc ep t i o n a ro u n d
preventive measures, which might correspond to
different periods and sample across member states.
Survey-based results may also 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 survival reflect the proportion of patients
with a certain type of cancer who are still alive after a
s p e c i f i e d t i m e p e r i o d ( c o m m o n ly f i ve ye a r s )
compared to those still alive in absence of the disease.
Relative survival captures the excess mortality that
can be attributed to the diagnosis. For example, a
relative survival 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 data presented here
have been age-standardised using the International
Cancer Survival Standard (ICSS) population. Survival
is 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.
References
European Centre for Disease Prevention and Control (2012),
Introduction of HPV vaccines in EU Countries: An Update,
Stockholm.
IARC International Agency for Research in Cancer (2012),
GLOBOCAN 2012: Cancer Fact Sheet, available at: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx.
OECD (2013), Cancer Care: Assuring Quality to Improve
Survival, OECD Publishing, http://dx.doi.org/10.1787/
9789264181052-en.
4.6. SCREENING, SURVIVAL AND MORTALITY FOR CERVICAL CANCER
4.6.1. Cervical cancer screening in women aged 20-69,

2002 to 2012 (or nearest year)
4.6.2. Cervical cancer five-year relative survival,

1997-2002 and 2007-12 (or nearest period)
2002
1997-2002
Austria 2
Latvia 2
Germany2
Sweden1
United Kingdom1
Slovenia1
France 2
Greece 2
Poland 2
Finland1
Spain 2
Cyprus 2
Ireland1
Denmark1
Netherlands1
Belgium1
EU25
Malta 2
Czech Republic1
Estonia1
Luxembourg1
Bulgaria 2
Italy1
Hungary1
Slovak Republic1
Romania 2
2012
Austria
81.5
80.5
67.9
Sweden
67.3
Netherlands
66.5
Denmark
66.4
Belgium
66.0
78.7
78.4
78.3
71.3
71.1
69.7
Finland
65.1
67.7
Czech Republic
64.9
67.3
Germany
64.5
69.1
2007-2012
67.9
64.9
64.2
64.2
63.2
60.3
Portugal
64.1
Slovenia
63.0
EU15
62.4
58.0
United Kingdom
51.5
50.0
48.7
46.8
60.9
Latvia
58.0
Ireland
57.2
41.0
36.7
22.9
14.6
Norway1
Switzerland 2
Iceland1
Turkey1
75.9
Poland
52.7
Malta
52.1
Norway
74.9
64.0
71.4
Iceland
70.5
12.2
25
50
75
100
Women screened (%)
1. Programme.
2. Survey.
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en
completed with Eurostat Statistics Database 2014 for non-OECD countries.
1 2 http://dx.doi.org/10.1787/888933155713
30
60
90
Survival (%)
Note: The 95% confidence intervals represented by H.

1 2 http://dx.doi.org/10.1787/888933155713
4.6.3. Cervical cancer mortality, females, 2000 to 2011

2000
2011

20
16.0
18
16
8.7
8.7
7.7
3.8
2.8
2.2
1.7
5.8
5.2
5.1
4.2
3.8
3.5
3.4
3.4
3.1
2.9
2.8
2.8
2.8
2.6
2.4
2.3
1.9
1.2
1.7
2.3
4.7
8.6
10.1
12
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10.4
12.2
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1 2 http://dx.doi.org/10.1787/888933155713
97
4.7. SCREENING, SURVIVAL AND MORTALITY FOR BREAST CANCER
Breast cancer is the most prevalent form of cancer

among women, with 367 000 new cases diagnosed each
year in Europe (IARC, 2012). Risk factors that increase a
persons chance of getting this disease include, but are not
limited to, age, family history of breast cancer, oestrogen
replacement therapy, lifestyle, nutrition and alcohol.
Variation in breast cancer care across European countries is
indicated by mammography screening rates in women
aged 50-69 years, relative survival, and mortality rates.
European Guidelines (European Commission, 2006)
promote a desirable breast cancer screening target of at
least 75% of eligible women in European member states, but
in 2010 only six 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 and 16% in the
Slovak Republic, to over 80% in Finland, Denmark, Austria
and the Netherlands (Figure 4.7.1). This variation may, in
part, be explained by programme longevity, with some
countries having well established programmes and others
commencing programmes more recently. However,
screening rates fell in a number of countries in the past
decade, including Finland, Ireland, Italy, the Netherlands,
Norway and Iceland. Rates in Estonia and Czech Republic
have increased substantially, although they remain below
the EU average.
Breast cancer survival reflects advances in improved
treatments as well as public health interventions to detect
the disease early through screening programmes and
greater awareness of the disease. The introduction of
combined breast conserving surgery with local radiation
and neoadjuvant therapy, for example, have increased
survival as well as the quality of life of survivors. The
ava i l ab i l i t y a n d u s e o f n ewe r a n d m o re e f f e c t ive
chemotherapy agents for metastatic breast cancer have
also been shown to improve survival among women.
The relative five-year breast cancer survival has
improved in many countries in recent periods (Figure 4.7.2),
reaching over 80% in all EU countries except Poland. In part,
this may be related to more limited access of care in Poland
where there are fewer cancer care centres and radiotherapy
facilities (OECD, 2013). Five-year survival for breast cancer
has increased considerably in central and eastern European
countries, where survival has historically been low, as well
as in Ireland. Recent studies suggest that some of the
differences in cancer survival could be due to variations in
the implementation of screening programmes. In addition
to well organised breast cancer screening programmes, a
recent OECD report on cancer care showed that shorter
waiting times and the provision of evidence-based best
practice are also associated with improved survival in OECD
countries. Developing comprehensive breast cancer control
plans, setting national targets with a specified time frame,
98
having guidelines, using case management and having

mechanisms for monitoring and quality assurance were
found to be associated with improved breast cancer
survival (OECD, 2013).
Mortality rates from breast cancer have declined in all
EU member states over the past decade except for Bulgaria,
Latvia and Croatia (Figure 4.7.3). The reduction in mortality
rates reflects improvements in early detection and
treatment of breast cancer and is also influenced by the
incidence of the disease. Improvements were substantial in
Austria, the Netherlands, the Czech Republic, as well as in
Malta. Denmark also reported an important decline over
the last decade, but its mortality rate was still the highest
in 2011.

M a m m o g ra p hy s c r e e n i n g ra t e s r e f l e c t t h e
proportion of eligible women who are actually
screened. As policies regarding target age groups and
screening periodicity differ to some extent across
countries, the rates are based on each countrys
specific policy. Some countries ascertain screening
based on surveys and others based on encounter data,
and this may influence results. Screening rates
reported by member states are calculated from Health
I nt e r v i ew S u r veys o n s e l f- p e rc ep t i o n a ro u n d
preventive measures, which might correspond to
different periods and sample across member states.
Survey-based results may also 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 is defined in Indicator 4.6 Screening,
survival and mortality for cervical cancer. See
Indicator 1.5 Mortality from cancer for definition,
source and methodology underlying the cancer
mortality rates.
References
European Commission (2006), European Guidelines for Quality
Assurance in Breast Cancer Screening and Diagnosis,
4th edition, Luxembourg.
IARC International Agency for Research on Cancer (2012),
OECD (2013), Cancer Care: Assuring Quality to Improve Survival,
9789264181052-en.
4.7. SCREENING, SURVIVAL AND MORTALITY FOR BREAST CANCER
4.7.1. Mammography screening in women aged 50-69,

2002 to 2012 (or nearest year)
4.7.2. Breast cancer five-year relative survival, 1997-2002

and 2007-12 (or nearest period)
2002
1997-2002
Finland1
Denmark1
Austria 2
Netherlands1
Spain 2
United Kingdom1
Portugal 2
Belgium 2
Ireland1
Luxembourg1
Slovenia1
Cyprus 2
EU25
Italy1
Poland 2
Germany1
France 1
Czech Republic1
Estonia1
Greece 2
Hungary1
Latvia 2
Malta 2
Bulgaria 2
Slovak Republic1
Romania 2
2012
84.8
Sweden
87.4
80.2
Finland
85.9
80.1
Netherlands
85.9
Slovenia
85.2
72.7
Belgium
85.0
72.2
Germany
85.0
Austria
84.1
Malta
83.2
EU15
82.9
81.5
77.1
76.5
73.6
71.9
69.8
59.4
57.7
57.5
57.1
Portugal
54.3
53.3
82.6
United Kingdom
52.7
82.0
Denmark
52.0
49.5
82.0
Czech Republic
46.4
41.7
80.7
Latvia
80.7
31.2
Ireland
21.9
16.0
80.5
Poland
8.0
Norway1
Iceland1
Switzerland 2
Turkey1
2007-2012
73.6
72.6
Iceland
59.0
44.8
25.5
25
87.1
Norway
50
75
100
Women screened (%)
86.1
1. Programme.
2. Survey.
completed with Eurostat Statistics Database for non-OECD countries.
1 2 http://dx.doi.org/10.1787/888933155729
20
40
60
80
100
Survival (%)
Note: The 95% confidence intervals are represented by H.

1 2 http://dx.doi.org/10.1787/888933155729
4.7.3. Breast cancer mortality, females, 2000 to 2011

2000
2011

70
38.2
33.6
26.0
31.8
41.8
41.8
41.3
39.8
39.2
38.3
38.2
37.2
37.0
36.9
36.8
36.1
34.5
33.2
33.1
33.0
32.4
32.3
31.5
30.7
30.6
30.1
29.2
28.2
28.2
27.5
30
25.5
40
32.3
50
44.1
60
20
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1 2 http://dx.doi.org/10.1787/888933155729
99
4.8. SCREENING, SURVIVAL AND MORTALITY FOR COLORECTAL CANCER
Colorectal cancer is the third most commonly diagnosed

form of cancer worldwide, after lung and breast cancers,
with 345 000 new cases diagnosed in the European Union
in 2012. Incidence rates are significantly higher for males
than females (IARC, 2012). 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. The disease is
more common in Europe and the United States, and is rare
in Asia. But in countries where people have adopted
western diets, such as Japan, the incidence of colorectal
cancer is increasing.
The European Council has recommended the implementation of population-based primary screening programmes using the faecal occult blood test (FOBT) for men
and women aged 50-74 years (European Commission, 2010).
Organised screening programmes are being introduced or
piloted in several countries and data on screening rates
have become available for some European countries.
Figure 4.8.1 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 4.6 and 4.7). Germany is a notable exception
where screening rates for colorectal cancer have reached
nearly 55% of the target population in 2008. 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 which might vary across
member states. The International Agency for Research on
Cancer has for example previously noted that there was
considerable variation in the way colorectal cancer screening programmes have been implemented across EU member states (IARC, 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 (OECD, 2013). Figure 4.8.2 shows
the five-year relative survival following colorectal cancer
diagnosis between 1997-2002 and 2007-12. In the 2007-12
period, the highest survival was observed in Belgium, at
nearly 65%. The figures indicate that survival improved in
all 11 countries for which survival data was available for
both periods, with countries such as Ireland and the Czech
Republic witnessing substantial gains in survival.
whereas eight countries saw an increase in colorectal

cancer mortality. 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, Croatia, Slovenia
and the Czech Republic.

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 first wave of the European
Health Interview Survey (EHIS) around 2008.
Survival is defined in Indicator 4.6 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 (colon, rectosigmoid
junction, rectum, and anus).
References
European Commission (2010), European Guidelines for Quality
Assurance in Colorectal Cancer Screening and Diagnosis
First Edition, European Commission, Brussels, available
online at: screening.iarc.fr/doc/ND3210390ENC.pdf.
ECHIM European Community Health Indicator Monitoring
(2012), Implementation of European Health Indicators First
Years: Final Report of the Joint Action for ECHIM, Helsinki,
Finland.
IARC International Agency for Research on Cancer (2012),
IARC (2008), Cancer Screening in the European Union, Report on
the implementation of the council recommendation on
cancer screening, edited by L. von Karsa, A. Anttila,
G. Ronco, A. Ponti, N. Mamila, M. Arbyn, N. Segnan et al.,
available at www.iarc.fr/fr/publications/pdfs-online/prev/
index2.php.
OECD (2013), Cancer Care: Assuring Quality to Improve Survival,
9789264181052-en.
Mortality rates reflect the effect of cancer care,

screening and diagnosis as well as changes in incidence.
Between 2000 and 2011, average EU mortality rates fell from
37.9 to 34.4 per 100 000 population, although the trend was
not uniform across all countries. Figure 4.8.3 shows that out
of 28 EU member states, 17 countries saw a decrease
100
4.8. SCREENING, SURVIVAL AND MORTALITY FOR COLORECTAL CANCER
4.8.1. Colorectal cancer screening in people aged 50-74,

Germany
4.8.2. Colorectal cancer, five-year relative survival,

1997-2002 and 2007-12 (or nearest period)
Czech Republic
Belgium
64.5
Germany
64.3
Sweden
63.9
Finland
63.8
Austria
63.3
Netherlands
62.9
Slovenia
62.6
25.3
France
20.8
Slovak Republic
18.6
Latvia
13.7
EU14
12.7
Bulgaria
11.4
Belgium
8.8
Hungary
Ireland
58.6
EU15
58.5
4.8
Cyprus
2007-2012
1997-2002
54.2
4.3
Portugal
Greece
3.8
Spain
3.5
Poland
3.5
Malta
2.6
Romania
55.5
Malta
55.4
United Kingdom
54.5
Czech Republic
53.4
1.9
Turkey
58.3
Denmark
Latvia
49.1
Poland
47.7
3.2
20
40
60
% of people screened
Norway
62.9
Note: Data based on surveys in all countries.

Source: Eurostat Statistics Database (based on EHIS).
1 2 http://dx.doi.org/10.1787/888933155732
25
50
75
100
Survival (%)
Note: The 95% confidence intervals are represented by H.

1 2 http://dx.doi.org/10.1787/888933155732
4.8.3. Colorectal cancer mortality 2000 to 2011

2011
2000
57.1
30.4
27.6
25.4
42.0
41.0
36.9
36.8
36.5
36.1
35.7
35.6
35.5
34.4
33.9
31.7
31.5
31.0
30.6
29.7
29.6
29.0
28.5
28.2
15.9
21.8
30
22.4
28.1
40
32.2
50
43.3
50.7
60
52.3

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1 2 http://dx.doi.org/10.1787/888933155732
101
4.9. CHILDHOOD VACCINATION PROGRAMMES
Vaccination programmes are among the safest and most

effective public health interventions to provide protection
against diseases such as diphtheria, tetanus and pertussis,
measles and hepatitis B. All EU member countries have
established vaccination schedules, recommending the
vaccines to be given at various ages during childhood.
Although there is strong evidence that childhood vaccines
are highly cost-effective health care intervention, too many
children in Europe go unvaccinated and remain vulnerable
to these potentially life-threatening diseases. Notably,
children from disadvantaged socio-economic groups such
as Roma migrants have a lower likelihood of receiving
vaccination, which calls for actions to design more effective
vaccination strategies.
Vaccination against diphtheria, tetanus and pertussis
(DTP) and measles are part of all national vaccination
schedules in Europe. Figures 4.9.1 and 4.9.2 show that the
overall vaccination of children against DTP and measles is
high in European countries. On average, 96% of 1-year-old
children received the recommended DTP vaccination and
94% received measles vaccinations in accordance with
national immunisation schedules. Rates for DTP vaccinations
are below 90% only in Austria, Romania and Iceland, while
vaccination rates against measles are below 90% only in
Austria, Cyprus, France and Serbia.
Although national coverage rates are high, some parts of
the population remain exposed to certain diseases. In 2013,
for example, there was a measles outbreak in the North of
England as well as parts of Wales. The outbreak was linked
to a time in the early 2000s when vaccination rates fell to
80% among a cohort of children. During this period there
was intense media coverage on the safety of the measles,
mumps and rubella (MMR) vaccine, leading many parents
to decide not to immunise their child. Although these
safety concerns have since been refuted, large numbers of
children in this age cohort remain unimmunised, raising
the likelihood of outbreaks such as the one experienced
in 2013.
Figure 4.9.3 shows the percentage of children aged one
year who are vaccinated for hepatitis B. The hepatitis B
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. A vaccination has been
available since 1982 and is considered to be 95% effective in
preventing infection and its chronic consequences. Since a
high proportion of chronic infections are acquired during
early childhood, the WHO recommends that all infants should
receive their first dose of hepatitis B vaccine as soon as
possible after birth, preferably within 24 hours (WHO, 2009).
102
M o s t E U c o u n t r i e s h av e f o l l o w e d t h e W H O
recommendation to incorporate hepatitis B vaccine as an
integral part of their national infant immunisation
programme (WHO/UNICEF, 2014). For these countries, the
immunisation coverage is averaging 94%. However, a
number of countries do not currently require children to be
vaccinated and consequently the rates for these countries
are significantly lower than other countries. For example, in
Denmark and Sweden, vaccination against hepatitis B is
not part of the general infant vaccination programme, but is
provided to high risk groups such as children with mothers
who are infected by the hepatitis B virus. Other European
countries that do not includ e vaccination ag ainst
hepatitis B in their infant programmes are Iceland, Finland,
Hungary, Slovenia, Switzerland and the United Kingdom. In
France, hepatitis B vaccination has been controversial but
vaccination coverage among children has increased in
recent years.

Vaccination rates reflect the percentage of children
at either age 1 or 2 who receive the respective
va c ci n a t i o n in t h e re co m m e n d e d t i me fra m e.
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.
References
WHO World Health Organization (2009), Hepatitis B WHO
Fact Sheet No. 204, WHO, Geneva.
WHO/UNICEF (2014), Immunization Schedule February
2014 Update, available at www.who.int/immunization_
monitoring/data/data_subject/en/index.html [accessed
9 July 2014].
4.9. CHILDHOOD VACCINATION PROGRAMMES
4.9.1. Vaccination against diphteria, tetanus

and pertussis, children aged 1, 2012
4.9.2. Vaccination against measles, children aged 1, 2012
Belgium
Cyprus
Czech Republic
Finland
France
Greece
Hungary
Luxembourg
Malta
Poland
Slovak Republic
Portugal
Sweden
Italy
Netherlands
Spain
United Kingdom
EU28
Croatia
Slovenia
Bulgaria
Ireland
Denmark
Estonia
Germany
Lithuania
Latvia
Romania
Austria
99
99
99
99
99
99
99
99
99
99
99
98
98
97
97
97
97
96
96
96
95
95
94
94
93
93
92
89
83
Greece
Hungary
Slovak Republic
Luxembourg
Czech Republic
Poland
Finland
Germany
Portugal
Spain
Sweden
Belgium
Netherlands
Croatia
Slovenia
EU28
Bulgaria
Estonia
Romania
Lithuania
Malta
United Kingdom
Ireland
Denmark
Italy
Latvia
France
Cyprus
Austria
99
99
99
99
98
98
97
97
97
97
97
96
96
95
95
94
94
94
94
93
93
93
92
90
90
90
89
86
76
Turkey
FYR of Macedonia
Norway
Switzerland
Montenegro
Serbia
Iceland
97
96
95
95
94
91
89
Turkey
FYR of Macedonia
Norway
Switzerland
Iceland
Montenegro
Serbia
98
97
94
92
90
90
87
25
50
75
100
% of children vaccinated
Source: WHO/UNICEF (2014), http://dx.doi.org/10.1787/health-data-en.

1 2 http://dx.doi.org/10.1787/888933155748
25
50
75
100

1 2 http://dx.doi.org/10.1787/888933155748
4.9.3. Vaccination against hepatitis B, children aged 1, 2012

100
80
90
96
96
97
74
83
86
91
93
93
94
94
94
95
95
96
96
96
97
98
98
98
98
98
99
99
60
40
20
y
te
ne
gr
ke
Tu
r
on
M
on
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ed
Se
ac
M
FY
of
ia
ia
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an
Fr
ria
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Au
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rm
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La
ta
M
al
Li
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ua
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21
EU
a
ni
Es
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la
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Lu
Bu
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Sp
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It a
ga
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Gr
Cr
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ak
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Cz
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1 2 http://dx.doi.org/10.1787/888933155748
103
4.10. INFLUENZA VACCINATION FOR OLDER PEOPLE
Influenza is a common infectious disease that affects

between 5 and 15% of the population each year (WHO, 2014).
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. Influenza can
also have a major impact on the health care system. In the
United Kingdom, an estimated 779 000 general practice
consultations and 19 000 hospital admissions were annually
attributable to influenza (Pitman et al., 2006).
Vaccines have been used for more than 60 years, and
provide a safe means of preventing influenza. While
influenza vaccines have shown positive results in clinical
trials and observational studies, there is a need for more
high quality studies on the effectiveness of influenza
vaccines for the elderly. Nevertheless, appropriate
influenza vaccines have been shown to reduce the risk of
death by up to 55% among healthy older adults as well as
reduce the risk of hospitalisation by between 32% and 49%
among older adults. In 2003, countries participating in the
World Health Assembly (WHA), 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).
Figure 4.10.1 shows that around 2012, across 21 EU
member states for which data were available, the average
influenza vaccination rate for people aged 65 and over was
43%. Vaccination rates across Europe range from 1% in
Estonia to 76% in the United Kingdom. Whilst there is still
some uncertainty about the reasons for such 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. 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. In Estonia, for example, influenza
vaccination is not publicly covered.
Figure 4.10.2 indicates that between 2002 and 2012,
vaccination rates across the European Union remained
stable. There is no uniform trend across Europe. Some
countries such as Germany have maintained their
vaccination rates over the last decade, countries such as the
Slovak Republic, France, Spain, Slovenia, Hungary, Finland,
Luxembourg, Ireland and the Netherlands have seen a
decrease in the rates while countries such as Denmark,
Italy, Belgium, Portugal, the United Kingdom and the Czech
Republic have seen a rise between 2002 and 2012. Only the
United Kingdom attained the 75% coverage target in 2012,
but this target was also nearly met in the Netherlands.
Changes over time should be interpreted with some caution
because of changes to the way vaccination rates were
calculated in some countries (see box on Definition and
comparability).
In June 2009, the WHO declared the first influenza
pandemic since 1968-69 (WHO, 2009). Within 23 weeks of
the first diagnosis of the H1N1 influenza virus (also referred
104
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. 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. 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.

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. A number of countries
changed the way in which influenza vaccination rates
were calculated between 2005 and 2012. These
countries are: Denmark, Germany, Luxembourg,
Switzerland and the United Kingdom.
References
ECDC European Centre for Disease Prevention and Control
(2011), Annual Epidemiological Report 2011. Reporting on
2009 Surveillance Data and 2010 Epidemic Intelligence Data,
ECDC, Stockholm.
Pitman, R.J., A. Melegaro, D. Gelb et al. (2006), Assessing the
Burden of Influenza and Other Respiratory Infections in
England andWales, Journal of Infection, Vol. 54, No. 6,
pp. 530-538.
WHA World Health Assembly (2003), Prevention and Control
of Influenza Pandemics and Annual Epidemics, 56th World
Health Assembly, World Health Organization, Geneva.
WHO World Health Organization (2014), Influenza (Seasonal)
Fact sheet No. 211, available at: www.who.int/mediacentre/
factsheets/fs211/en/index.html [accessed 9 July 2014].
WHO (2009), New Influenza A (H1N1) Virus: Global Epidemiological Situation, Weekly Epidemiological Record,
Vol. 84, pp. 249-257, June.
4.10. INFLUENZA VACCINATION FOR OLDER PEOPLE
4.10.1. Vaccination rates for influenza, population aged 65 and over, 2012 (or nearest year)
%
100
90
80
76
74
70
65
64
63
60
57
57
56
53
50
45
43
43
46
43
41
40
36
35
29
30
22
20
17
15
13
12
11
10
ak
ov
ay
y
ke
rw
No
Sl
Cz
Tu
r
Sw
it z
Es
er
to
la
ni
nd
ic
la
pu
Re
Po
bl
ia
ic
en
bl
ov
ec
Lu
Sl
Re
Hu
pu
nl
ng
an
ar
ria
Fi
ce
st
ee
Gr
Au
21
De
nm
EU
ar
ga
g
ur
xe
Po
r tu
ce
bo
an
Fr
Ge
rm
an
nd
la
ly
ai
Ir e
Sp
It a
ed
Sw
lg
Be
er
th
en
iu
nd
la
do
ng
Ki
Ne
d
i te
Un
nd
1 2 http://dx.doi.org/10.1787/888933155759
4.10.2. Trends in vaccination rates for influenza, population aged 65 and over, 2002-12 (or nearest year)
2002
%
100
2012
90
80
78
76
74
69
70
67
65
60
58
67
63
62
57
55
57
56 56
53
50
46 45
47 47
43
40
43
43
37
37
35
32
29
30
26
22
20
17
17
10
15
ic
ov
ak
Sl
Re
ov
pu
en
bl
ia
ic
Sl
Cz
ec
Re
Hu
pu
ng
bl
ar
d
nl
Fi
ar
nm
De
an
l
r tu
ga
16
Po
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EU
ur
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Fr
Ge
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Ir e
n
ai
Sp
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1 2 http://dx.doi.org/10.1787/888933155759
105

OECD 2014
Chapter 5
Access to care
5.1. Coverage for health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
108
5.2. Out-of-pocket medical expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . .
110
5.3. Geographic distribution of doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
112
5.4. Unmet health care needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
114
5.5. Waiting times for elective surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
116
107
5.1. COVERAGE FOR HEALTH CARE
Health care coverage enables access to medical goods

and services and provides financial protection against
unexpected or serious illness (European Commission,
2014). While the share of the population covered by a public
or private health insurance provides some indication of
financial protection, this is not a complete indicator of
accessibility, since the range of services covered and the
degree of cost-sharing applied to those services vary across
countries and will impact on direct out-of-pocket
expenditure by patients (Indicator 5.2). Ensuring effective
access to health care also requires having a sufficient
number of health care providers in different geographic
regions in the country (Indicator 5.3) and that patients do
not have to wait excessively long times to receive services
(Indicator 5.5).
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 (especially for
children) and the purchase of prescribed pharmaceuticals
are also at least partially covered (Paris et al., 2010). Three
European countries do not have universal or near-universal
health coverage (Bulgaria, Greece and Cyprus).
In Bulgaria and Greece, the share of the population
covered has decreased in recent years. In Bulgaria, a
tightening of the law in 2010 made people lose their social
health insurance coverage if they fail to pay their
contribution (Dimova et al., 2012). However, it is common
for uninsured people who need medical care to go to
emergency services, where they will be encouraged to get
an insurance (without paying any financial penalty for not
having had an insurance prior to that). In Greece, the
economic crisis has reduced health insurance coverage
among people who have become long-term unemployed,
and many self-employed workers have decided not to
renew their health insurance plan because of reduced
disposable income. However, since June 2014, uninsured
people are covered for prescribed pharmaceuticals and for
services in emergency departments in public hospitals, as
well as for non-emergency hospital care under certain
conditions (Eurofound, 2014). In Cyprus, an estimated 83%
of the population were entitled to public health services
in 2007 (latest available year), although many are seeking
medical care in the private sector and pay out-of-pocket.
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 costs h arin g le ft afte r ba si c c ove rag e ( com ple m en tary
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 five countries,
108
half or more of the population had a private health

insurance in 2012 (Figure 5.1.2).
In France, nearly all the population (95%) has a
complementary private health insurance to cover costsharing 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 (88% of
the population), whereby private insurance pays for
prescribed pharmaceuticals and dental care that are not
covered in the basic package. Duplicate markets, providing
faster private-sector access to medical services where there
are waiting times in public systems, are largest in Ireland
(45%).
While the population covered by private health
insurance has grown over the past decade in some
countries like France, Belgium and Germany, there has been
a reduction in private health insurance coverage in recent
years in other countries like Spain and Ireland (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 the development of the private health
insurance market, including the history of health care
financing arrangements and government interventions to
promote the take-up of private health insurance.

Coverage for health care is defined as 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.
Pu blic coverag e re fers both to govern men t
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-incomerelated, although the purchase of private coverage can
be subsidised by the government.
References
Dimova, A. et al. (2012), Bulgaria: Health System Review, Health
Systems in Transition series, Vol. 14, No. 3, pp. 1-186.
Eurofound (2014), Access to Healthcare in Times of Crisis, Dublin.
European Commission (2014), Communication from the
Commission on Effective, Accessible and Resilient
Health Systems, com(2014)215 final, Brussels.
Paris, V., M. Devaux and L. Wei (2010), Health Systems
Institutional Characteristics: A Survey of 29 OECD Countries, OECD Health Working Paper, No. 50, OECD Publishing, Paris, http://dx.doi.org/10.1787/5kmfxfq9qbnr-en.
5.1. COVERAGE FOR HEALTH CARE
5.1.1. Health insurance coverage for a core set of services,

5.1.2. Private health insurance coverage, by type, 2012

(or nearest year)
Total public coverage

Primary private health coverage
Croatia
Czech Republic
Denmark
Finland
Hungary
Ireland
Italy
Latvia
Lithuania
Malta
Portugal
Romania
Slovenia
Sweden
United Kingdom
Austria
France
Spain
Germany
Netherlands
Belgium
Luxembourg
Slovak Republic
Estonia
Poland
Cyprus (2007)
Greece (2013)
Bulgaria (2011)
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
99.9
99.9
99.0
95.0
88.0
Belgium
79.6
Slovenia
72.8
Luxembourg
52.7
Ireland
44.6
Austria
Germany
34.5
10.9
21.4
32.4
Denmark
27.1
Malta
0.9
10.9
22.0
Cyprus
21.5
Portugal
20.2
Finland
14.4
Spain
13.4
Greece
12.5
Latvia
83.0
79.0
77.0
7.0
Bulgaria
3.0
Lithuania
100.0
99.8
100.0
100.0
100.0
100.0
98.3
80
Duplicate
France
99.8
99.0
97.0
95.0
93.3
91.0
70
Complementary
Supplementary
Netherlands
88.9
FYR of Macedonia
Iceland
Montenegro
Norway
Serbia
Switzerland
Turkey
Primary
1.0
0.2
Switzerland
27.9
Turkey
Iceland
90
100
Percentage of total population
Note: The coverage rate for Luxembourg is underestimated since the

number of European civil servants and their family's members is
unknown.
European Observatory Health Systems in Transition (HiT) Series for nonOECD countries.
1 2 http://dx.doi.org/10.1787/888933155766
5.5
0.2
20
40
60
80
100
Percentage of total population
Note: Private health insurance can fulfil several roles. In Austria and
D e n m a r k , f o r e x a m p l e, i t c a n b e b o t h c o m p l e m e n t a ry a n d
supplementary.
European Observatory Health Systems in Transition (HiT) Series for nonOECD countries.
1 2 http://dx.doi.org/10.1787/888933155766
5.1.3. Trends in private health insurance coverage, 2000 to 2012

Belgium
%
100
France
Germany
Ireland
Spain
80
60
40
20
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
1 2 http://dx.doi.org/10.1787/888933155766
109
5.2. OUT-OF-POCKET MEDICAL EXPENDITURE
Financial protection through either public coverage or

private health insurance can substantially reduce the
amount that people pay directly for medical care. In some
countries, the burden of high out-of-pocket spending can
create barriers to accessing and using health care services:
households that face difficulties paying medical bills may
delay or even forgo needed health care. On average across EU
member states, a fifth of all health spending is paid directly by
patients (see Indicator 6.5 Financing of health care).
In contrast to publicly funded care, out-of-pocket
payments rely on peoples ability to pay. If the financing of
health care becomes more dependent on out-of-pocket
payments, the burden is transferred, in theory, towards
those who use services more, and possibly from high to
low-income earners, where health care needs are typically
higher. In practice, many countries have policies in place to
protect vulnerable groups from excessive out-of-pocket
payments. These consist of partial or total exemptions for
people receiving social benefits, seniors, or people with
chronic diseases or disabilities by capping direct payments,
either in absolute terms or as a share of income (Paris et al.,
2010; Paris et al., forthcoming).
The burden of out-of-pocket medical spending can be
measured as a proportion of spending by households on the
whole range of their consumption of goods and services.
The share allocated to medical spending varied considerably
across EU member states in 2012, ranging from 1.5% or less
of total household consumption in the United Kingdom,
Croatia and France, to more than 4% in Cyprus, Bulgaria,
Malta, Portugal and Hungary (Figure 5.2.1). On average,
across the European Union, 2.9% of household spending
went towards medical services.
Health systems in EU member states differ in the degree
of coverage for different health services and goods. In most
countries, coverage is higher for hospital care and doctor
consultations than for pharmaceuticals, dental care and
eye care (Paris et al., 2010; Paris at al., forthcoming). Taking
into account these differences as well as the relative
importance of these different spending categories, there are
significant variations between EU member states in the
breakdown of the medical costs that households have to
bear themselves.
In most EU member states, curative care (covering both
inpatient and outpatient care) and pharmaceuticals are the
two main spending items for out-of-pocket expenditure
(Figure 5.2.2). On average, these two components account
for more than 70% of all medical spending by households,
but the importance varies between countries. In Cyprus
and Luxembourg, inpatient and outpatient curative care
accounts for 50% or more of total household medical
spending. In other countries such as Romania, Croatia,
Lithuania, Poland, Estonia, the Czech Republic and
110
Hungary, more than half of all out-of-pocket payments are

for pharmaceuticals. In some of these countries, in addition
to co-payments for prescribed pharmaceuticals, spending
on over-the-counter medicines for self-medication is
historically high.
Dental treatment is also an important part of household
medical spending, accounting for 16% of all out-of-pocket
expenditure on average across EU countries. This figure
reaches as much as 30% in Spain and Denmark, as well as
in Norway and Iceland. This can at least partly be explained
by the limited public coverage for dental care in these
countries compared with the relatively good coverage for
other categories of care. The significance of therapeutic
appliances (e.g. eye-glasses, hearing aids, etc.) in
households total medical spending differs widely but
reaches over 30% in the Netherlands. The average across
EU countries is 13%. More than half of this relates to eyecare products. In many countries, public coverage is limited
to a contribution to the cost of lenses. Frames are often
exempt from public coverage, leaving private households to
bear the full cost if they are not covered by complementary
private insurance.

Out-of-pocket payments are expenditures borne
directly by a patient where neither public nor private
insurance cover the full cost of the health good or
service. They include cost- sharing and other
expenditure paid directly by private households and
also include in some cases estimations of informal
payments to health care providers. Only expenditure
for medical spending (i.e. current health spending less
expenditure for the health part of long-term care) is
presented here, because the capacity of countries to
estimate private long-term care expenditure varies
widely.
References
Paris, V., M. Devaux and L. Wei (2010), Health Systems
Institutional Characteristics: A Survey of 29 OECD Countries, OECD Health Working Paper, No. 50, OECD Publishing, Paris, http://dx.doi.org/10.1787/5kmfxfq9qbnr-en.
Paris, V. et al. (forthcoming), Health Care Coverage in OECD
Countries, OECD Health Working Paper, OECD Publishing.
5.2. OUT-OF-POCKET MEDICAL EXPENDITURE
5.2.1. Out-of-pocket medical spending as a share of final household consumption, 2012 (or nearest year)
%
5
4.9
5.0
4.9
4.7
4.2
4.1
3.7
3.7
3.3
3.2
3.2
3.2
3.2
2.9
2.9 2.9
2.9
2.9
2.8
2.8
2.5
2.4
2.3
2.0
1.9
1.8
1.8
1.7
1.6
1.5
1.5
1.3
1.2
No
Tu
r
ke
ay
rw
nd
an
la
el
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Sw
Cy
p
Bu r us
lg
ar
ia
M
al
t
Po a
r tu
Hu g a l
ng
a
Be r y
lg
iu
m
Gr
ee
c
Sw e
ed
e
Sl
o v Ir e n
ak la
n
Re d
pu
Li blic
th
ua
ni
a
La
tv
ia
EU
28
Sp
ai
Fi n
nl
an
d
It a
Au l y
st
ri
Po a
la
nd
D
Cz
e c enm
h
a
Re r k
pu
bl
Es ic
to
S ni a
Lu love
xe ni
m a
bo
G e ur g
rm
Ro a n y
Ne ma
t h ni a
er
la
nd
Fr s
an
c
Un
i t e Cr o e
d
a
Ki tia
ng
do
m
Note: This indicator relates to current health spending excluding long-term care (health) expenditure.
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; Eurostat Statistics Database and WHO Global Health Expenditure Database for
non-OECD countries.
1 2 http://dx.doi.org/10.1787/888933155779
5.2.2. Shares of out-of-pocket medical spending by services and goods, 2012 (or nearest year)
Curative care 1
%
100
13
14
10
10
13
16
15
21
24
12
13
31
41
27
31
52
34
42
48
27
22
45
27
29
27
36
12
60
1
8
28
15
70
Other
13
14
23
80
Therapeutic appliances 2
Pharmaceuticals
6
13
90
Dental care
40
26
56
61
51
62
77
70
37
50
33
19
10
40
26
16
29
20
7
21
16
33
30
29
62
30
8
49
43
20
39
37
34
33
32
31
30
16
15
12
55
22
13
10
29
28
28
26
10
26
21
20
18
18
15
13
12
27
25
d
an
Ic
el
ay
rw
la
er
it z
No
nd
tia
Cr
oa
ia
an
ni
m
Ro
ni
to
Es
nd
ua
s
nd
la
Po
th
Li
Sw
Ne
th
er
la
bl
bl
pu
Re
h
ec
Cz
ak
ov
Sl
ic
ic
n
Re
pu
Sp
ai
an
ar
rm
Ge
ia
21
nm
De
EU
en
an
ov
Sl
en
nl
Fi
ia
ce
tv
ed
Sw
La
an
Fr
ar
ria
ng
Hu
m
iu
st
Au
lg
ur
Be
bo
Lu
xe
Cy
pr
us
Note: This indicator relates to current health spending excluding long-term care (health) expenditure.
1. Including rehabilitative and ancillary services.
2. Including eye care products, hearing aids, wheelchairs, etc.
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; Eurostat Statistics Database for non-OECD countries.
1 2 http://dx.doi.org/10.1787/888933155779
111
5.3. GEOGRAPHIC DISTRIBUTION OF DOCTORS
Access to medical care requires an adequate number

and proper distribution of physicians in all parts of the
country. Shortages of physicians in certain regions can
increase travel times or waiting times for patients, and
result in unmet care needs. The uneven distribution of
physicians is an important concern in most European
countries, especially in those countries with remote and
sparsely populated areas, and those with deprived urban
regions which may also be underserved.
The overall number of doctors per capita varies across EU
countries from lows of about 2 to 2.5 per 1 000 population in
Poland, Romania and Slovenia, to highs of more than 4 in
Greece, Austria and Lithuania (Indicator 3.1). Beyond these
cross-country differences, the number of doctors per capita
also often varies widely across regions within the same
country (Figure 5.3.1). A common feature in many countries
is that there tends to be a concentration of physicians in
capital cities. In the Czech Republic, for example, the density
of physicians in Prague is almost twice the national average.
Austria, Greece, Portugal and the Slovak Republic also have a
much higher density of physicians in their national capital
region.
The density of physicians is consistently greater in
urban regions, reflecting the concentration of specialised
services such as surgery and physicians preferences to
practice in urban settings. Differences in the density of
doctors between predominantly urban regions and rural
regions in 2011 was highest in the Slovak Republic, Czech
Republic and Greece, driven to a large extent by the strong
concentration of doctors in their national capital region
(Figure 5.3.2).
Doctors may be reluctant to practice in rural and
disadvantaged urban regions due to various concerns about
their professional life (e.g. income, working hours,
opportunities for career development, isolation from peers) and
social amenities (such as educational opportunities for their
children and professional opportunities for their spouse).
A range of policy levers may influence the choice of
practice location of physicians, including: 1) the provision of
financial incentives for doctors to work in underserved
areas; 2) increasing enrolments in medical education
programmes of students coming from specific social or
geographic background, or decentralising medical schools;
3) regulating the choice of practice location of doctors (for all
new medical graduates or possibly targeting more
specifically international medical graduates); and 4) reorganising health service delivery to improve the working
conditions of doctors in underserved areas and find
innovative ways to improve access to care for the population.
In many European countries, different types of financial
incentives have been provided to doctors to attract and
retain them in underserved areas, including one-time
112
subsidies to help them set up their practice and recurrent

payments such as income guarantees and bonus payments
(Ono et al., 2014).
In Germany, the number of practice permits for new
ambulatory care physicians providing services to statutory
health insurance patients in each region is regulated, based
on a national service delivery quota (Federal Joint Committee,
2012). In France, new multi-disciplinary medical homes
were introduced a few years ago as a new form of group
practices in underserved areas, allowing physicians and
other health professionals to work in the same location
while remaining self-employed.
The effectiveness and costs of different policies to
promote a better distribution of doctors can vary significantly,
with the impact likely to depend on the characteristics of each
health system, the geography of the country, physician
behaviours, and the specific policy and programme design.
Policies should be designed with a clear understanding of
the interests of the target group in order to have any
significant and lasting impact (Ono et al., 2014).

I n d i c a t o r 3. 1 p rovi d e s i n f o r ma t i o n o n t h e
definition of doctors.
The NUTS classification (Nomenclature of territorial
units for statistics) is a hierarchical system used to
divide the territorial units of the European Union for
the purpose of the collection, development and
harmonisation of EU regional statistics. The higher
level (Territorial Level 2) consists of large regions
corresponding generally to national administrative
regions. These broad regions may contain a mixture of
urban, intermediate and rural areas. The lower level
(Territorial Level 3) is composed of smaller regions
which are classified as predominantly urban,
intermediate or predominantly rural regions.
References
Federal Joint Committee (2012), Planning Guideline of the Federal Joint Committee, Federal M inistry of Justice
(Germany).
Ono, T., M. Schoenstein and J. Buchan (2014), Geographic
Imbalances in Doctor Supply and Policy Responses,
OECD Health Working Papers No. 69, OECD Publishing,
Paris, http://dx.doi.org/10.1787/5jz5sq5ls1wl-en.
5.3. GEOGRAPHIC DISTRIBUTION OF DOCTORS
5.3.1. Physician density, by NUTS 2 level, 2012 (or nearest year)

Austria
Vienna
Belgium
Bulgaria
Croatia
Czech Republic
Prague
Denmark
Finland
France
Germany
Attica (Athens Region)
Greece
Hungary
Italy
Netherlands
Poland
Portugal
Lisbon
Slovak Republic
Bratislava
Slovenia
Spain
Navarra
Sweden
United Kingdom
Norway
Switzerland
Turkey
0
8
9
10
Density per 1 000 population
1 2 http://dx.doi.org/10.1787/888933155782
5.3.2. Physician density in predominantly urban and rural regions, selected countries, 2011 (or nearest year)
Urban areas
Rural areas
Density per 1 000 population

9
8.3
7.5
7.2
6.7
6
5.1
5.1
4.6
4.5
3.6
4.4
3.6
2.6
4.0
3.3
3.8
3.2
2.7
2.5
2.4
2.2
4.4
4.1
2.0
1.3
y
ke
la
er
it z
Sw
Tu
r
nd
ay
No
rw
m
iu
lg
Be
Fr
an
ce
d
an
nl
Fi
en
ed
Sw
ar
ng
Hu
Po
r tu
ga
ic
bl
pu
Re
ak
ov
Sl
Cz
ec
Re
Gr
pu
ee
bl
ce
ic
Source: OECD (2013), OECD Regions at a Glance, 2013, http://dx.doi.org/10.1787/reg_glance-2013-en.
1 2 http://dx.doi.org/10.1787/888933155782
113
5.4. 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.
In Greece, the percentage of people reporting some

unmet medical care needs for financial reasons has
increased since the beginning of the crisis in 2008, rising
from around 4% of the population in 2008 to over 6% in 2011
and 2012, according to EU-SILC. This proportion reached
11% among people in the lowest income quintiles in 2012,
up from 7% in 2008.
Some common reasons given for not receiving care

include excessive costs, having to travel too far to receive care,
long waiting times, or not being able to take time off.
Differences in the reporting of unmet care needs across
countries may be partly due to socio-cultural differences.
However, these factors play a lesser role in explaining any
differences among population groups within each country.
Self-reported unmet care needs must be seen 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 and 5.2).
By contrast, in Portugal, the percentage of people

reporting unmet medical care needs for financial reasons
was lower in 2011 and 2012 compared with the years before
the crisis. These results from EU-SILC have also been found
in the European Quality of Life Surveys (EQLS): 34% of
Portuguese respondents to this EQLS survey reported
having some difficulties accessing care due to cost in 2011,
less than the 49% who reported having such difficulties
in 2007 (Eurofound, 2013). The MoU that the Portuguese
Government signed in May 2011 with the EU Commission,
the IMF and the ECB (the troika) included a series of
measures to reduce public spending on health, but it also
included certain measures to protect access to care,
particularly for low-income groups. For example, while copayments for a range of health services were increased for
most of the population, the number of patients exempted
from such co-payments was increased through increasing
the income threshold (Eurofound, 2014; see chapter by
Rodrigues and Schulmann).
In all European countries, a large majority of the

population reported no unmet care needs, according to the
2012 EU Statistics on Income and Living Conditions
survey (EU-SILC). However, in some countries, significant
proportions of people reported having unmet needs. In
Latvia, Poland, Romania and Bulgaria, more than 10% of
survey respondents had an unmet need for a medical
examination, and the burden fell heaviest on low income
groups, particularly in Latvia and Bulgaria (Figure 5.4.1). On
average across EU member states, more than twice as many
people in low income groups reported unmet needs as did
people in high income groups. The main reason for people
in low income groups to report unmet health care needs
was that care was too expensive.
A larger proportion of the population indicates unmet
needs for dental care than for medical care (Figure 5.4.2). In
many countries, 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. People in Latvia
reported the highest rates of unmet need for a dental
examination in 2012 (over 20% of the population), followed by
Portugal, Romania, Bulgaria, and Italy (all between 10-15%).
There are large inequalities in unmet dental care needs
between high and low income groups in most of these
countries. People in Slovenia, the Netherlands and
Luxembourg reported the lowest rates of unmet dental care
needs in 2012 (between 1% and 3% only), according to EU-SILC.
Unmet needs for medical care and dental care due to
financial reasons have decreased between 2005 and 2008 on
average across EU countries, and have remained fairly
stable on average between 2008 and 2012 (Figures 5.4.3
and 5.4.4). The proportion of people in low-income groups
reporting some unmet needs for medical care and dental
care for financial reasons continues to be two-times greater
than among all the population as a whole, and over fourtimes greater compared with people in high-income groups
on average across EU countries.

Questions on unmet health care needs are included
in the European Union Statistics on Income and Living
Conditions survey (EU-SILC). To determine unmet
medical and dental care, individuals are asked
whether there was a time in the previous 12 months
when they felt they needed health care or dental care
but did not receive it, followed by a question as to why
the need for care was unmet. Reasons given include
that care was too expensive, the waiting time was too
long, or the distance to travel was too far.
Cultural factors may affect responses to questions about
unmet care needs. Caution is therefore required in
comparing the magnitude of inequalities across countries.
Income quintile groups are computed on the basis
of the total equivalised disposable income attributed
to each member of the household. The first quintile
group represents the 20 % of the population with the
lowest income, and the fifth quintile group represents
the 20 % of the population with the highest income.
References
Eurofound (2014), Access to Healthcare in Times of Crisis,
Dublin, including a country report on Portugal by
R. Rodrigues and K. Schulmann.
Eurofound (2013), Impacts of the Crisis on Access to Healthcare
Services in the EU, Dublin.
114
5.4. UNMET HEALTH CARE NEEDS
5.4.1. Unmet need for a medical examination

(for financial or other reasons), by income quintile, 2012
High income
Average
5.4.2. Unmet need for a dental examination (for financial

or other reasons), by income quintile, 2012
Low income
High income
Latvia
Poland
Romania
Bulgaria
Sweden
Estonia
Greece
Hungary
Croatia
EU28
Italy
Finland
Germany
Spain
Portugal
Denmark
Slovak Republic
France
Cyprus
Czech Republic
Lithuania
Luxembourg
Ireland
United Kingdom
Belgium
Malta
Austria
Netherlands
Slovenia
Latvia
Portugal
Romania
Bulgaria
Italy
Cyprus
Spain
Poland
Greece
France
Sweden
Estonia
EU28
Hungary
Ireland
Finland
Denmark
Belgium
Austria
Lithuania
Czech Republic
Croatia
Slovak Republic
United Kingdom
Germany
Malta
Luxembourg
Netherlands
Slovenia
Iceland
Norway
Switzerland
Iceland
Norway
Switzerland
0
10
20
30
40
%
Average
10
Low income
20
30
40
%
Note: 2011 data for Austria and Ireland.

Source: Eurostat Statistics Database, based on EU-SILC.
1 2 http://dx.doi.org/10.1787/888933155793
Note: 2011 data for Austria and Ireland.

1 2 http://dx.doi.org/10.1787/888933155793
5.4.3. Change in unmet medical care need for financial

reasons, average across EU countries, 2005 to 2012
5.4.4. Change in unmet dental care need for financial

reasons, average across EU countries, 2005 to 2012
Low income
High income
Average
10
10
Low income
High income
Average
0
2005
2006
2007
2008
2009
2010
2011
2012

1 2 http://dx.doi.org/10.1787/888933155793
2005
2006
2007
2008
2009
2010
2011
2012

1 2 http://dx.doi.org/10.1787/888933155793
115
5.5. WAITING TIMES FOR ELECTIVE SURGERY
Long waiting times for health services is an important

policy issue in many European countries (Siciliani et al.,
2013a). Long waiting times for elective (non-emergency)
surgery generates dissatisfaction for patients because the
expected benefits of treatments are postponed, and the
pain and disability remains.
Waiting times is the result of a complex interaction
between the demand and supply of health services, where
doctors play a critical role on both sides. The demand for
health services and for elective surgery is determined by
the health status of the population, patient preferences
(including their weighting of the expected benefits and
risks of different procedures), and the extent of cost-sharing
for patients. However, doctors play a crucial role in converting
the demand for better health from patients in a demand for
medical care. On the supply side, the availability of different
categories of surgeons, anaesthesists and other staff involved
in surgical procedures, as well as the supply of the required
equipment is likely to influence surgical activity rates.
The measure presented here focuses on waiting times
from the time that a specialist adds a patient to the waiting
list to the time that the patient receives the treatment. The
waiting times relate to three frequent non-emergency surgical
interventions: cataract surgery, hip replacement and knee
replacement. Both the average waiting times and the median
are presented. Because some patients wait for very long times,
the average is usually greater than the median.
In 2012/13, the average waiting times for cataract
surgery was just over 30 days in the Netherlands, but about
three-times longer (100 days) in Spain and Finland
(Figure 5.5.1). In the United Kingdom, the average waiting
times for cataract surgery was almost 70 days in 2012,
slightly shorter than in 2006, but longer than in 2008 and
2010. Waiting times for cataract surgery has come down
over the past few years in some countries, such as the
Netherlands and Denmark (and also Estonia, based on the
median waiting times). In Portugal and Spain, waiting times
fell between 2006 and 2010, but has increased since 2010.
In 2012/13, the average waiting times for hip replacement
was less than 40 days in the Netherlands, but almost fourtimes longer (around 150 days) in Spain and Hungary
(Figure 5.5.2). In Portugal and Finland, the average waiting
times to get a hip replacement was around 120 days, while
in the United Kingdom, it was 90 days. The median waiting
times was about 40 days in Denmark and 75 days in Hungary.
It was highest in Poland (slightly more than 200 days),
followed by Spain and Estonia (around 150 days). Waiting
times for hip replacement in the United Kingdom fell
sharply between 2006 and 2008, but has remained stable
since then. In Portugal and Spain, following significant
reductions between 2006 and 2010, waiting times for hip
replacement has increased since 2010.
Waiting times for knee replacement has come down over
the past few years in some countries such as the Netherlands,
Denmark, Finland and Estonia, although it remains very long
in Estonia (Figure 5.5.3). In the United Kingdom, waiting times
for knee replacement followed the same pattern as for hip
116
replacement: it fell markedly between 2006 and 2008, but has

remained stable since then. In 2012/13, the median waiting
times for knee replacement was longest in Poland, Estonia,
Portugal and Spain.
Over the past decade, waiting time guarantees have
become the most common policy tool to tackle long waiting
times in several countries. This has been the case in Finland
where a National Health Care Guarantee was introduced
in 2005 and led to a reduction in waiting times for elective
surgery (Jonsson et al., 2013). In England, since April 2010, the
NHS Constitution has set out a right to access certain services
within maximum waiting times or for the NHS to take all
reasonable steps to offer a range of alternative providers if this
is not possible, including a right to start non-emergency
treatment within a maximum of 18 weeks from referral if that
is what the patient wants and is clinically appropriate (Smith
and Sutton, 2013).

There are at least two ways of measuring waiting
times for elective procedures (Siciliani et al., 2013b):
1) measuring the waiting times for patients treated in a
given period; or 2) measuring waiting times for patients
still on the list at a point in time. The data reported
here relate to the first measure (data based on the
second measure are available in OECD Health Statistics).
The data come from administrative databases (not
surveys). Waiting times are reported both in terms of
the average and the median. The median is the value
which separates a distribution in two equal parts
(meaning that half the patients have longer waiting
times and the other half lower waiting times).
Compared with the average, the median minimises the
influence of outliers (patients with very long waiting
times).
References
Jonsson, P.M. et al. (2013), Finland, Part II, Chapter 7 in
Waiting Time Policies in the Health Sector: What Works,
9789264179080-en.
Siciliani, L., M. Borowitz and V. Moran (2013a), Waiting Time
Policies in the Health Sector: What Works?, OECD Health
Policy Studies, OECD Publishing, Paris, http://dx.doi.org/
10.1787/9789264179080-en.
Siciliani, L., V. Moran and M. Borowitz (2013b), Measuring
and Comparing Health Care Waiting Times in OECD Countries, OECD Health Working Papers No. 67, OECD Publishing,
Paris, http://dx.doi.org/10.1787/5k3w9t84b2kf-en.
Smith, P. and M. Sutton (2013), United Kingdom, Part II,
Chapter 16 in Waiting Time Policies in the Health Sector:
What Works, OECD Publishing, Paris, http://dx.doi.org/
10.1787/9789264179080-en.
5.5. WAITING TIMES FOR ELECTIVE SURGERY
5.5.1. Cataract surgery, waiting times from specialist assessment to treatment, 2006 to 2012/13
2006
Days
350
2008
2010
2013 (or 2012)
300
250
200
150
100
50
Average
Poland
Spain
Finland
Estonia
Portugal
Denmark
United Kingdom
Hungary
Spain
Finland
Portugal
Hungary
Denmark
United Kingdom
Netherlands
Median
1 2 http://dx.doi.org/10.1787/888933155805
5.5.2. Hip replacement, waiting times from specialist assessment to treatment, 2006 to 2012/13
2006
Days
250
2008
2010
2013 (or 2012)
200
150
100
50
Average
Poland
Spain
Estonia
Finland
Portugal
United Kingdom
Hungary
Denmark
Spain
Hungary
Portugal
Finland
United Kingdom
Denmark
Netherlands
Median
1 2 http://dx.doi.org/10.1787/888933155805
5.5.3. Knee replacement, waiting times from specialist assessment to treatment, 2006 to 2012/13
2006
Days
400
2008
2010
2013 (or 2012)
350
300
250
200
150
100
50
Average
Poland
Estonia
Portugal
Spain
Finland
Hungary
United Kingdom
Denmark
Hungary
Spain
Portugal
Finland
United Kingdom
Denmark
Netherlands
Median
1 2 http://dx.doi.org/10.1787/888933155805
117

OECD 2014
Chapter 6
Health expenditure and financing
6.1. Health expenditure per capita. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
120
6.2. Health expenditure in relation to GDP . . . . . . . . . . . . . . . . . . . . . . . . . .
122
6.3. Health expenditure by function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
124
6.4. Pharmaceutical expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
126
6.5. Financing of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
128
6.6. Trade in health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
130
119
6.1. HEALTH EXPENDITURE PER CAPITA
There are large variations in the levels and rates of

growth of health spending across Europe. How much a
country spends on health and the rate at which this
expenditure grows reflect a wide array of economic and
social factors, as well the financing and organisational
structures of its health system.
also suffered significant reversals in per capita health

spending after previously strong growth.
There is a strong relationship between the overall income

level of a country and how much the country spends on
health. It is therefore not surprising that Norway and
Switzerland are the two European countries that spent the
most on health in 2012 (Figure 6.1.1), with spending of over
EUR 4 500 per person (adjusted for countries different
purchasing powers see the box on Definition and comparability). Among EU member states, the Netherlands
(EUR 3 829), Austria (EUR 3 676) and Germany (EUR 3 613)
were the highest per-capita spenders, well above the
EU average (EUR 2 193). Romania (EUR 753) and Bulgaria
(EUR 900) were the lowest-spending countries among EU
members. Of the other European states outside the European
Union, health spending per capita was of a similarly low
level in Montenegro, the Former Yugoslav Republic of
Macedonia and Turkey.
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.
Figure 6.1.1 shows the breakdown of per capita spending

on health into public and private sources (see also
Indicator 6.5 Financing of health care). On average, around
three-quarters of health spending comes from public sources
and the ranking by public share of spending is similar to
overall health spending. Of the EU member states, only
Cyprus sees private spending on health outweighing public
financing, though Latvia and Bulgaria also have high levels
of private spending. By contrast, the Netherlands,
United Kingdom and most of the Nordic countries have
levels of public financing exceeding 80%.
Since the onset of the economic crisis in 2008, health
spending has slowed markedly across Europe after years of
continuous growth. Between 2009 and 2012, expenditure on
health in real terms (adjusted for inflation) fell in half of EU
countries and significantly slowed in the rest (Figure 6.1.2).
On average across the European Union, health spending
decreased by 0.6% each year between 2009 and 2012,
compared with annual growth of 4.7% between 2000 and
2009. Of the countries outside the European Union, only the
Former Yugoslav Republic of Macedonia and Switzerland
have seen growth rates increase since 2009.
While health budgets were maintained at the start of the
economic crisis in many countries, health spending per capita
began to fall in 2009 in some of the countries hardest hit by
the economic crisis (e.g. Estonia and Iceland). More
widespread reductions were observed in 2010 and 2011 in
response to fiscal pressures and the need to reduce large
deficits and debts (Morgan and Astolfi, 2014).
By 2012, a number of countries began to experience
renewed growth in health spending, albeit at much lower
rates compared to the pre-crisis period. However, health
spending continued to fall in 2012 in Greece, Italy, Portugal
and Spain, as well as in the Czech Republic and Hungary.
Greece has seen per capita health spending fall by 9%
each year since 2009 after yearly growth of more than 5%
between 2000 and 2009, leaving the per capita level 25%
lower in 2012 than in 2009. Ireland and the Slovak Republic
120
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.
For the calculation of growth rates in real terms,
economy-wide GDP de flators are used for all
countries. In some countries (e.g. France and Norway)
health-specific deflators exist, based on national
methodologies, but these are not used in this
publication due to limited comparability.
References
Morgan, D. and R. Astolfi (2014), Health Spending Continues
to Stagnate in Many OECD Countries, OECD Health
Working Paper No. 68, OECD Publishing, Paris, http://
dx.doi.org/10.1787/5jz5sq5qnwf5-en.
OECD (2000), A System of Health Accounts, Version 1.0,
9789264181809-en.
OECD, Eurostat and WHO (2011), System of Health Accounts
2011, OECD Publishing, Paris, http://dx.doi.org/10.1787/
9789264116016-en.
-10
-0.3
3.1
2.8
1.4
1.9
2.1
1.2
1.0
1.6
5.2
4.9
2.5
3.4
3.1
2.2
3.1
1.6
2.1
1.8
8.4
7.4
7.7
2000-09
1.5
1 133
957
651
739
783
1 845
1 728
1 560
1 086
900
753
2 003
1 809
1 354
1 219
2 243
2 655
2 193
3 437
3 220
3 318
2 921
2 470
3 613
3 528
3 083
2 672
2 409
1 921
1 580
1 156
934
1 000
-2.4
3.9
3.8
7.1
9.1
10.9
1 500
1.0
2.2
1.3
3.4
1.4
0.9
0.9
7.3
5.8
10
0.4
2.0
0.8
4.0
4.7
It a
ly
Sp
ai
n
EU
Sl 2 8
ov
en
ia
M
Po al t
r tu a
ga
Gr l 1
e
e
Sl
ov C c e
a yp
C z k Re r us
e c pu
h
Re b l i c
pu
Hu b l i c
n
L i g ar
th y
ua
n
Po i a
la
n
Cr d
oa
Es tia
to
ni
La a
tv
Bu i a
lg
Ro a r i a
m
an
ia
No
Sw r w
i t z ay
er
la
Ic nd
el
an
d
M S er
on b
i
te a
FY
ne
R
g
of Tu ro
M rk
ac ey
ed
on
ia
2 000
-0.4
-0.5
0.0
0
-0.6
-1.0
1.8
6.9
2 500
-1.1
-1.2
3.3
4.9
4.0
4.1
3 000
-1.3
-1.4
-1.9
-2.5
2.2
6.3
3 500
-3.3
-3.6
3.5
3 829
3 676
4 565
4 610
Public
el
an
Tu d
rk
e
Se y
r
No bi a
F Y Sw r w
R
a
of it ze y
M rla
ac nd
ed
on
ia
-5
-3.7
-5.1
0.6
4 500
-9.0
er
la
nd
Au s 1
Ge s tr i
rm a
D any
L u enm
xe ar
m k
bo
B e ur g
lg
iu
m
Fr 1
an
Sw ce
ed
e
Ir e n
la
Un
n
i t e F in d
d
K i land
ng
do
m
th
4 000
5.4
Ne
EUR PPPs
5 000
Ic
L u Gr
xe e e c
m e
bo
ur
Ir e g
la
n
Cr d
oa
Po t i a
r tu
g
C y al
pr
us
Sp
ai
Un
i te L n
d at v
Ki
ng ia
d
De om
nm
ar
Sl
k
ov
ak It
Re al y
pu
bl
ic
EU
C z Sl 2 8
e c ov
e
h
Re ni a
pu
b
Es lic
to
Ro n i a
m
an
Fr i a
an
c
Po e
la
nd
Fi
nl
a
Be nd
lg
iu
Au m
st
Sw ria
ed
L i en
th
ua
Hu ni a
ng
Ge ar y
Ne rm
th an
er y
la
n
Bu ds
lg
ar
ia
M
al
ta
6.1. HEALTH EXPENDITURE PER CAPITA
6.1.1. Health expenditure per capita, 2012 (or nearest year)

Private
500
1. Current health expenditure.

Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; Eurostat Statistics Database; WHO Global Health Expenditure Database.
1 2 http://dx.doi.org/10.1787/888933155816
6.1.2. Annual average growth rate in per capita health expenditure, real terms, 2000 to 2012 (or nearest year)
Annual average growth rate (%)

15
2009-12
-15
1 2 http://dx.doi.org/10.1787/888933155816
121
6.2. HEALTH EXPENDITURE IN RELATION TO GDP
In 2012, EU member states devoted an (unweighted)

ave rag e o f 8 . 7 % o f t h e i r G D P t o h e a l t h s p e n d i n g
(Figure 6.2.1), up significantly from 7.3% in 2000. A peak of
9.0% was reached in 2009 following the economic crisis
which started in many countries in mid-2008. In many
countries, public spending on health was maintained in the
immediate aftermath of the crisis while GDP fell, but this
was followed in 2010 and 2011 by a range of measures to
rein in government health spending as part of broader
efforts to reduce budgetary deficits.
Among EU member states, the Netherlands allocated
the highest share of its GDP to health in 2012 (11.8%),
followed by France and Germany (at 11.6% and 11.3%
respectively). The shares of the highest-spending European
countries remain well below that of the United States,
where health expenditure accounted for 16.9% of GDP
in 2012. The share of health spending in GDP was lowest in
Romania, Latvia and Estonia at below 6%. Outside the
European Union, Switzerland was on par with the high
spending EU states, with 11.4% of GDP spent on health,
while Turkey allocated 5.4% of its GDP to health. Capital
spending, which covers investments in the health sector
during the year, accounted on average for 0.3% of GDP
in 2012.
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 6.1). 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, Luxembourg and Croatia both spent around 7%
of their GDP on health in 2012; however, per capita
spending (adjusted to EUR PPPs) was three times higher in
Luxembourg (see Figure 6.1.1).
In France and Germany, the health spending to GDP

ratio increased from just over 10% in 2000 to more than 11%
in both countries in 2012 (Figure 6.2.2). 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, health spending as a share of
G D P i n c re a s e d ra p i d ly f ro m s o m ew h a t b e l ow t h e
EU average in 2000 to above the average by 2006. As in many
other European countries, the share of health spending
allocated to GDP in the United Kingdom increased by
almost a full percentage point in 2009 following the
economic crisis, but has since reduced slightly.

See Indicator 6.1 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.
Changes in the ratio of health spending to GDP are the

result of the combined effects of growth in both GDP and
health expenditure. Even taking into account the economic
crisis, between 2000 and 2012, the annual average growth in
health expenditure per capita in real terms was about 3.3%
on average in EU member states, greater than the growth
rate in GDP per capita. Among the EU-28, with the
exception of Croatia, Latvia and Luxembourg, annual
growth in health spending outpaced GDP growth from 2000
to 2012, explaining why the share of GDP allocated to health
increased in all these countries.
122
6.2. HEALTH EXPENDITURE IN RELATION TO GDP
6.2.1. Health expenditure as a share of GDP, 2012 (or nearest year)

Current
Capital
7.1
9.0
7.6
9.3
5.4
5.7
5.6
5.9
6.8
6.7
7.2
7.1
7.4
7.4
8.0
7.5
8.7
8.1
9.1
8.9
9.2
9.1
9.3
9.3
9.4
9.3
9.6
9.5
10
10.5
11.4
11.0
10.9
11.3
11.1
11.8
12
11.6
% GDP
14
4
2
Ne
th
er
la
nd
Fr s
an
Ge c e
rm
a
Au ny
st
De r ia
nm
B e ar k
lg
i
S w um
ed
Po en
r tu
Sl g a l
ov
en
Un
ia
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d Sp a
Ki
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do
Gr m
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It a
l
M y
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ta 1
Fi
nl
an
Ir e d
la
Sl
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ov
ak EU
Re 2 8
pu
b
C z Hu l i c
ec ng
h
Re ar y
p
Bu ub l i
lg c
ar
i
Cy a 1
pr
u
L u Cr o s
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m ia
bo
u
Po r g
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Li nd
th
ua
n
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to
ni
La a
t
Ro v i a 1
m
an
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Sw
it z
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la
n
Se d 1
rb
No ia 1
rw
a
I
F Y Mo c el y
R nt an
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1
M eg
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on
i
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ey 1
1. Total expenditure only (no breakdown between current and capital spending available).
1 2 http://dx.doi.org/10.1787/888933155821
6.2.2. Health expenditure as a share of GDP, 2000-12,

selected European countries
France
Germany
United Kingdom
6.2.3. Health expenditure as a share of GDP, 2000-12,

selected European countries
Italy
Estonia
EU28
Portugal1
% GDP
12
Greece
Ireland
EU28
% GDP
12
10
10
4
2000
2002
2004
2006
2008
2010
2012

1 2 http://dx.doi.org/10.1787/888933155821
2000
2002
2004
2006
2008
2010
2012
1. Data refer to current expenditure (excluding capital spending).

1 2 http://dx.doi.org/10.1787/888933155821
123
6.3. HEALTH EXPENDITURE BY FUNCTION
Spending on inpatient care and outpatient care covers

the major part of health expenditure across EU member
states almost two-thirds of current health expenditure on
average in 2012 (Figure 6.3.1). A further quarter of overall
health spending was allocated to medical goods (mainly
pharmaceuticals), while 10% went towards long-term care
and the remaining 6% to collective services, including
public health and prevention services and administration.
Greece stands out as the European country with the
highest share of spending on inpatient care (including day
care in hospitals): it accounted for almost half of total
health spending in 2012, a significant increase from 2011 as
a consequence of a larger decrease in spending on
outpatient care and pharmaceuticals. In France, Romania,
Austria and Poland, the hospital sector also plays an
important role, with inpatient spending comprising more
than a third of total cost. On the other hand, Portugal,
Cyprus and Sweden have a high share of outpatient
spending representing more than 40% of health expenditure
in those countries.
The other major category is spending on medical goods.
Differences in the consumption patterns of pharmaceuticals
and relative prices are some of the main factors explaining
the variations in medical goods spending among countries.
In the Slovak Republic and Hungary, medical goods
represent the largest spending category at more than a
third of overall health expenditure. They also account for
30% or more in Lithuania, Croatia, Romania and Latvia. In
Denmark, Norway and Switzerland, on the other hand,
spending on medical goods represents only 10-11% of total
health spending.
There are also differences among countries in their
expenditure on long-term care. Countries such as Norway,
the Netherlands and Denmark, which have established
formal arrangements for the elderly and the dependent
population, allocate around a quarter of all health spending
to long-term care. In many southern and central European
countries with a more informal long-term care sector, the
expenditure on formal long-term care services accounts for
a much smaller share of total spending.
The economic crisis affected health spending growth in
many EU countries, resulting in substantially lower
spending growth since 2009. In order to curb public
spending, governments introduced a number of measures,
such as cuts in health sector workforce and salaries,
reductions in the fees paid to health providers and the
prices for pharmaceuticals, and increases in co-payments
for patients (Morgan and Astolfi, 2013).
The resulting s lowdown in health ex penditu re
experienced in many European countries affected all health
spending categories to varying degrees (Figure 6.3.2). Both
inpatient and outpatient care saw average spending growth
decrease significantly, especially from 2010 onwards, in
contrast to the high growth rates seen prior to the economic
crisis. Pharmaceutical spending has continued to shrink, on
average, for the last three years from 2010 to 2012, mainly
due to government price reduction policies (see also
124
Indicator 6.4). Many countries also took early measures to

reduce or postpone spending on prevention and public
health services, with a slight recovery in spending observed
since 2011. The strong increase in 2009 is due partially to
the H1N1 influenza pandemic which led to significant oneoff expenditures for the purchase of large stocks of vaccines
in many countries. Administration was another category
immediately targeted in cost-cutting efforts. Cuts in
administrative budgets were an initial response to the
financial crisis in many countries, such as in the Czech
Republic, where the budget of the Ministry of Health was
reduced by 30% between 2008 and 2010. Across all
EU member states, administrative expenditure stagnated
in 2010 and 2011 before growing again in 2012.

The System of Health Accounts (OECD, 2000; OECD,
Eurostat, WHO, 2011) defines the boundaries of the
health care system. Current health expenditure
comprises personal health care (curative care,
rehabilitative care, long-term care, ancillary services
and medical goods) and collective services
(prevention and public health services as well as
health administration). Curative, rehabilitative and
long-term care can also be classified by mode of
production (inpatient, day care, outpatient and home
care). Concerning long-term care, only the health
aspect is normally reported as health expenditure,
although it is difficult in certain countries to separate
out clearly the health and social aspects of long-term
care. Some countries with comprehensive long-term
care packages focusing on social care might be ranked
surprisingly low based on SHA data because of the
exclusion of their social care. Thus, estimations of
long-term care expenditure are one of the main
factors limiting comparability across countries.
References
Morgan, D. and R. Astolfi (2013), Health Spending Growth
at Zero: Which Countries, Which Sectors Are Most
Affected?, OECD Health Working Papers, No. 60, OECD
Publishing, Paris, http://dx.doi.org/10.1787/5k4dd1st95xv-en.
OECD (2000), A System of Health Accounts, Version 1.0, OECD
P u b l i s h i n g , Pa r i s , h t t p : / / d x . d o i . o rg / 1 0 . 1 7 8 7 /
9789264181809-en.
9789264116016-en.
6.3. HEALTH EXPENDITURE BY FUNCTION
6.3.1. Current health expenditure by function, 2012 (or nearest year)

Inpatient care 1
%
100
Outpatient care 2
3
90
16
27
80
23
11
13
25
10
11
50
30
12
20
23
19
35
24
23
36
11
17
11
20
29
19
28
32
34
30
29
29
22
11
31
13
Prevention and administration

4
15
19
25
10
43
30
28
22
35
31
26
14
40
17
24
24
8
22
3
14
60
Medical goods ("mainly pharmaceuticals")
10
32
30
70
19
25
21
Long-term care
36
28
42
36
30
22
33
28
45
33
38
35
25
28
28
27
34
30
20
47
38
36
36
36
33
31
31
31
31
31
30
30
29
29
29
29
29
28
27
26
23
10
nd
ak
Sw
it z
er
la
an
Ic
Re
No
el
rw
bl
ai
pu
Sp
ay
ic
ga
ar
Po
r tu
m
Hu
ng
iu
ur
lg
bo
m
ov
Lu
xe
Be
en
ar
Sw
ed
tia
nm
De
ia
oa
Cr
tv
an
Ge
rm
an
nl
Fi
La
ni
Sl
Cz
ec
Ne
th
er
Es
to
ia
la
nd
ic
en
bl
pu
Sl
Re
h
Li
ov
a
ni
EU
23
us
ua
th
nd
pr
Cy
ria
la
Po
ia
Au
st
an
ce
Ro
an
Fr
Gr
ee
ce
Note: Countries are ranked by inpatient care as a share of current health expenditure.
1. Refers to curative-rehabilitative care in inpatient and day care settings.
2. Includes home-care and ancillary services.
1 2 http://dx.doi.org/10.1787/888933155831
6.3.2. Average annual growth rates of spending for selected functions, EU average, in real terms
2007/08
%
10
2008/09
2009/10
2010/11
8.7
8.6
8.2
8
6.5
6.4
5.7
5.4
4
2
2011/12
3.2
2.9
2.5
2.2
1.9
1.5
0.7
1.9 1.8
1.8
1.0
0.5
0.2
0
-0.3
-0.4
-2
0.0
-0.3
-1.3
-1.7
-1.3
-2.7
-4
-3.8
-3.5
-6
Inpatient care
Outpatient care
Long-term care
Pharmaceuticals
Prevention
Administration
1 2 http://dx.doi.org/10.1787/888933155831
125
6.4. PHARMACEUTICAL EXPENDITURE
Spending on pharmaceuticals accounted for almost a

fifth of all health expenditure on average across EU member
states in 2012, making it the third largest spending
component after inpatient and outpatient care.
The total pharmaceutical bill across the European Union
approached EUR 200 billion in 2012. However, there are
wide variations in pharmaceutical spending per capita
across countries, reflecting differences in volume, structure
of consumption and pharmaceutical prices (Figure 6.4.1, left
panel). At EUR 550, Belgium spent more on pharmaceuticals
in 2012 than any other European country on a per capita
basis. Germany (EUR 501) and Ireland (EUR 500) also spent
40% more on medicines than the EU average, which stood
at EUR 350 per capita. At the other end of the scale,
Denmark, Latvia and Romania had relatively low spending
levels, below or around EUR 200 on a per capita basis.
Pharmaceutical spending accounted for 1.5% of GDP on
average across EU member states with a little under twothirds financed publicly and the rest from private sources.
Across the European Union, the pharmaceutical spending
as a share of GDP ranged from less than 1% in Luxembourg
and Denmark, to over 2% in Hungary, Greece and the
Slovak Republic (Figure 6.4.1, right panel). Public funding of
pharmaceuticals ranged from 0.3% of GDP in Denmark and
Cyprus to as much as 1.5% of GDP in Greece.
The economic crisis has had a significant effect on the
growth in pharmaceutical spending in many European
countries (Figure 6.4.2). Between 2000 and 2009, annual
pharmaceutical expenditure per capita grew by 3.7% in real
terms on average in EU member states, but fell in the
following three consecutive years. On average, pharmaceutical
spending fell by over 2% per year in real terms between 2009
and 2012 across EU member states. In three-quarters of EU
countries, pharmaceutical spending has dropped in real
terms since 2009 and in all EU member states, without
exception, the average growth rates between 2009 and 2012
were below those of the pre-crisis period. The reduction
was particularly steep in those countries that were hit
hardest by the recession. In Greece, pharmaceutical
spending per capita has decreased by more than 12% per
year since 2009, following high growth rates in the
preceding years. In 2012, pharmaceutical spending per capita
in Greece was 33% lower than in 2009 in real terms.
Luxembourg (-7.2%), Denmark (-6.1%), Portugal (-6.1%), Spain
(-5.2%), Italy (-3.9%) and Cyprus (-3.5%) as well as the
EU candidate Iceland (-4.9%) also experienced substantial
annual reductions in pharmaceutical spending in the years
since 2009. But lower pharmaceutical spending has also
been the case in European economies that weathered the
financial crisis fairly well: annual growth rates decreased
on average in Poland (-2.2%), Switzerland (-1.0%) and
Germany (-0.4%).
manufacturers, introduction of reference pricing,

application of compulsory rebates, decrease of pharmacy
margins, reductions of the value added tax applicable for
pharmaceuticals), centralised public procurement of
pharmaceuticals, promoting the use of generics, reduction
of package sizes, reduction in coverage (excluding
pharmaceuticals from reimbursement) and increases in
co-payments by households.
For example, Spain introduced a general rebate
applicable for all medicines prescribed by NHS physicians
in 2010. In addition, it mandated price reductions for
generics which is one of the factors explaining the growth
in the consumption of generics in that country. In Germany,
compulsory rebates for manufacturers were raised in 2011
and prices frozen until 2013. Since 2011, pharmaceutical
companies have been mandated to enter into rebate
negotiations with health insurance funds for new
innovative drugs, which put an end to the previous freepricing regime. In Italy, some of the spending reduction
can be attributed to the implementation of tighter
pharmaceutical budgets for the Italian regions as well as
reductions in wholesale and pharmacy margins, and price
cuts on generics based on a reference pricing. In Hungary,
the introduction of new mandatory tendering processes for
publicly-financed medications has started to bring
pharmaceutical spending down, while in Denmark, as in
many other countries, negative growth was partially due to
patent expirations of high-volume and high-cost brand
name drugs.

Pharmaceutical expenditure covers spending on
pharmaceuticals used in ambulatory care and does
not include the costs of medicines used in hospitals as
these are captured in estimates of inpatient spending
(resulting in an under-estimation of around 15% in
total pharmaceutical spending approximately).
Pharmaceutical expenditure covers both prescription
medicines and self-medication, often referred to as
over-the-counter products. Final expenditure on
pharmaceuticals includes wholesale and retail
margins and value-added tax. It also includes
pharmacists remuneration when the latter is
separate from the price of medicines.
Many European countries introduced a range of

measures to curb pharmaceutical spending: price cuts
(achieved through negotiations with the pharmaceutical
126
6.4. PHARMACEUTICAL EXPENDITURE
6.4.1. Expenditure on pharmaceuticals per capita and as a share of GDP, 2012 (or nearest year)
Pharmaceutical expenditure per capita
Total (no breakdown)
Prescribed
Pharmaceutical expenditure as a share of GDP
Over-the-counter
Public
Belgium
Germany
Ireland1
France
Greece 1
Hungary
Austria
Slovak Republic1
Italy1
Portugal1
Slovenia
EU25
Finland
Spain
Netherlands1
Lithuania1
Sweden
550
501
500
469
450
413
411
402
386
369
358
350
346
345
338
337
334
313
286
272
234
224
216
214
195
311
286
800
600
1.5
1.8
2.3
2.5
1.3
2.1
1.5
1.8
1.8
1.5
1.2
1.5
1.0
1.8
1.1
1.6
2.0
1.2
0.6
1.4
1.3
1.6
1.5
0.7
Switzerland
Iceland
Norway
422
1 000
EUR PPP
1.8
1.6
Czech Republic
Croatia
Cyprus
Luxembourg
Poland
Estonia
Romania
Latvia
Denmark
292
400
200
Private
1.1
1.3
0.6
4
% GDP
1. Includes medical non-durables (resulting in an over-estimation of around 5-10%).

1 2 http://dx.doi.org/10.1787/888933155842
6.4.2. Average annual growth in pharmaceutical expenditure1 per capita, in real terms, 2000 to 2012 (or nearest year)
2000-09
2009-12
Annual average growth rate (%)

15
10.0
10
10.2
8.5
5
0
-0.6
-5
-5.2
-6.1
-6.1
-7.2
8.0
4.8
3.7
3.4
3.3
2.2
1.6
1.3
0.9
8.0
2.4
1.9
-3.5
-1.0
-1.3
-1.3
-1.6
-1.7
-2.2
-2.2
-2.4
-2.9
-2.9
-3.3
3.1
2.0
0.1
1.7
-0.3
-3.9
4.6
3.1
0.9
2.21.8
1.8
0.9
6.1
4.9
3.2
2.5
1.2
-0.2
-1.2
-0.4
-1.0
-4.9
-10
-12.4
it z
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la
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an
rw
Sw
No
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a
Ro
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tv
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ar
Sl
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ria
Hu
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Au
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an
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Ge
ce
Re
pu
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an
an
Fr
ec
Cz
en
nl
Fi
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24
nd
iu
lg
Be
EU
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la
Po
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ni
pu
to
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Sl
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Ir e
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Sp
ga
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-15
1. Including medical non-durables.

1 2 http://dx.doi.org/10.1787/888933155842
127
6.5. FINANCING OF HEALTH CARE
Across all European countries, health care is financed by

a mix of public and private spending. In some countries,
public health spending is generally confined to spending by
the government using general revenues. In others, social
insurance funds finance the bulk of health expenditure.
Private financing of health care consists mainly of
payments by households (either as standalone payments or
as part of co-payment arrangements) as well as various
forms of private health insurance intended to replace,
complement or supplement publicly-financed coverage.
In all but one EU country (Cyprus), the public sector is
the primary source of health care financing. On average
across EU countries, three-quarters of all health care
spending was publicly financed in 2012. In Denmark, the
United Kingdom and Sweden, the central, regional or local
governments finance more than 80% of all health spending.
In t h e C z e ch R ep u bl i c , t h e N e t h e r l a n d s , C ro a t i a ,
Luxembourg, France and Germany, social health insurance
is the dominant financing scheme, funding 70% or more of
all health expenditure. Only in Cyprus was the share of
public spending on health below 50% with a larg e
proportion of health spending (47%) financed directly by
households. Although not the dominant financing scheme,
private health insurance also finances a significant
proportion 10% or more of total health spending in
Slovenia, Ireland, France and Germany. The nature of the
private health insurance, however, varies in these countries
(see Indicator 5.1 Coverage for health care).
Governments provide a multitude of services for their
populations from the public budget. Hence, health care is
competing for resources with many different sectors such
as education, defence and housing. The size of the public
budget allocated to health is determined by a number of
factors including, among others, the type of health and
long-term care system, the demographic composition of
the population, and the relative budget priorities in
countries, which can change from year to year. On average
across the European Union, 14% of total government
expenditure was dedicated to health care (Figure 6.5.2).
T h e re a re, h ow eve r, i m p o r t a n t va r i a t i o n s a c ro s s
EU member states. In the Netherlands and Germany, one
euro out of every five spent by the government is allocated
to health care. A similar share is also seen in Switzerland
(22%). On the other hand, this falls to less than one out of
every EUR 10 spent by governments in Cyprus and Latvia.
After public financing, the main source of funding tends
to be out-of-pocket payments. On average, households
financed a fifth of all health spending across EU member
states in 2012. This share is above 30% in Cyprus, Bulgaria,
Latvia, Lithuania, Malta and Portugal, while it was lowest in
countries such as the Netherlands (6%), France (8%) and the
United Kingdom (9%).
On average across EU countries, the share of out-ofpocket spending has remained stable over the past
five years. But this average hides significant differences
across countries. In Portugal, Lithuania, Hungary and
Ireland, the share increased by more than 2 percentage
128
points since 2007. In some of these countries, public

coverage for certain services was reduced in response to
public financing constraints and a growing share of
payments was transferred to households. In Portugal, for
example, user charges for some types of vaccinations and
health certificates issued by doctors were introduced.
Moreover, public coverage for some pharmaceuticals was
reduced. In Ireland, entitlement for public coverage was
removed for some sections of the wealthier population,
while prescription charges were introduced and coverage
for dental care reduced (Mladovsky et al., 2012).
In a number of other countries, the share of spending by
private households fell over the same period. Estonia, Belgium
and Poland have all seen drops of about 2 percentage points
or more.

The financing of health care can be analysed from
t h e p o i n t o f v i ew o f t h e s o u rc e s o f f u n d i n g
(households, employers and the state), financing
schemes (e.g., compulsory or voluntary insurance),
and financing agents (organisations managing the
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 expenditure by the
general government and social security funds. Private
f i n a n c i n g c o v e r s h o u s e h o l d s o u t - o f - p o ck e t
payments, private health insurance and other private
funds (NGOs and private corporations). Out-of-pocket
payments are expenditures borne directly by patients.
They include cost-sharing and, in certain countries,
estimations of informal payments to health care
providers.
Total government expenditure is used as defined in
the System of National Accounts (SNA 2008) and
includes as major components intermediate
consumption, compensation of employees, subsidies,
interest, social benefits and transfers in kind, current
transfers and capital transfers payable by central,
regional and local governments as well as social
security funds.
References
Mladovsky P. et al. (2012), Health Policy Responses to the
Financial Crisis in Europe, Policy Summary 5, World
Health Organization.
OECD (2000), A System of Health Accounts, Version 1.0,
9789264181809-en.
9789264116016-en.
6.5. FINANCING OF HEALTH CARE
6.5.1. Expenditure on health by type of financing, 2012 (or nearest year)

Social security
General government
% of current expenditure
100
2
5
5
6
90
13
3
9
15
12
8
17
19
18
14
13
80
1
19
10
12
17
4
20
20
21
6
15
23
13
70
22
1
24
Private insurance
1
13
32
29
32
17
34
Other
15
32
29
11
43
47
78
40
85
84
79
74
68
81
69
77
74
77
40
64
70
69
60
30
67
64
1
67
58
66
63
61
54
33
11
11
th
Un
59
57
53
46
20
17
Ne
37
52
29
7
37
rw
Ic a y
el
T and
F Y S ur k e
R w i y 2,
3
of t ze
M rla
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on
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M Se
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ne
gr
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er
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i te Den ds 1
d
m
C z K in ar k
e c gd
h
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L u epu
xe b l
m ic
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u
Sw rg
e
Ro d e n
m
an
Es ia
to
n
Cr i a
oa
t
Fr i a
an
ce
It
Ge al y 2
rm
a
Au ny
st
Be ria
lg
iu
Fi m
nl
an
Sl
d
ov
ak EU
Re 2 8
pu
Sl blic
ov
en
ia
Sp
ai
Po n
la
n
Gr d
ee
Ir e c e
l
Li and 2
th
ua
n
M ia
al
ta 2
La
t
v
Po i a
r tu
Hu g a l
ng
Bu ar y
lg
ar
C y ia
pr
us
12
36
No
33
10
77
74
38
46
20
0
39
65
26
29
1
45
7
18
15
15
60
50
Private out-of-pocket
1. The Netherlands do not account for fixed deductable payable by patients (350 EUR per year) as out-of-pocket spending, resulting in an underestimation of the share of out-of-pocket payments.
2. Data refer to total health expenditure.
3. Public spending cannot be split.
1 2 http://dx.doi.org/10.1787/888933155850
6.5.2. Health expenditure as share of total government

expenditure, 2012 (or nearest year)
Netherlands1
Germany
Austria
United Kingdom
France
Denmark
Slovak Republic
Sweden
Belgium
Czech Republic
Ireland
Italy
Spain
Slovenia
Luxembourg
EU28
Portugal
Malta
Croatia
Romania
Lithuania
Finland
Estonia
Bulgaria
Greece
Poland
Hungary
Latvia
Cyprus
Portugal1
Lithuania
Hungary
Ireland
Romania
Czech Republic
Bulgaria
Luxembourg
Spain
Malta
Greece
EU26
France
Latvia
Sweden
Italy
Germany
Netherlands1
Austria1
Finland
United Kingdom
Slovenia
Denmark
Cyprus
Poland
Belgium
Estonia
20
19
16
16
16
16
15
15
15
14
14
14
14
14
14
14
13
13
13
12
12
12
12
12
12
11
10
9
8
Switzerland
Norway
Iceland
FYR of Macedonia
Serbia
Turkey
Montenegro
22
18
15
14
13
11
10
10
15
20
25
% total government expenditure
1. Data refer to current health expenditure.

OECD National Accounts; Eurostat Statistics Database; WHO Global Health
Expenditure Database.
1 2 http://dx.doi.org/10.1787/888933155850
6.5.3. Change in out-of-pocket expenditure as share of

total expenditure on health, 2007 to 2012 (or nearest year)
4.5
3.8
2.9
2.1
1.9
1.8
1.7
1.6
1.4
1.0
0.4
0.3
0.1
0.1
0.0
-0.1
-0.6
-0.6
-0.6
-0.7
-1.0
-1.1
-1.5
-1.5
-1.9
-1.9
-3.8
Montenegro
Serbia
Iceland
Switzerland
FYR of Macedonia
Turkey
5.1
2.3
2.0
1.2
1.0
-6.4
-10
-5
5
10
Percentage points
1. Data refer to current health expenditure.

Eurostat Statistics Database; WHO Global Health Expenditure Database.
1 2 http://dx.doi.org/10.1787/888933155850
129
6.6. TRADE IN HEALTH SERVICES
The globalisation of health care has given rise to new

patterns of consumption and production of health care
services over recent decades. A significant new element of
the trade in health care has involved the movement of
patients across borders in the pursuit of medical treatment:
a phenomenon commonly termed medical tourism. This
g row t h h a s b e e n f u e l l e d by a nu m b e r o f f a c t o r s .
Technological advances in information systems and
communication allow patients or purchasers of health care
to seek out quality treatment at lower cost and/or more
immediately from health care providers in other countries.
The portability of health coverage, as a result of EU-wide
measures to facilitate patient flows with regard to public
health insurance systems, may also fuel further increases.
All this is coupled with a general increase in the temporary
movement of populations for business or leisure.
While the major part of international trade in health
services involves the physical movement of patients across
borders to receive treatment, to get a full measure of imports
and exports, there are also other aspects such as 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 spending for health services and goods by
residents abroad (imports) are available for most European
countries. They amounted to more than EUR 3 billion
in 2012. However, due to data gaps and under-reporting,
this is also likely to be a significant underestimate. The vast
majority of this trade is among European countries. With
health-related imports reaching over EUR 1 700 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 (Figure 6.6.1). Even in the case of Germany,
reported imports represent only around 0.6% of Germanys
health expenditure. The share rises above 1% of health
spending in Iceland, Portugal and the Netherlands, and up
to 3.5% in Cyprus as there is a higher level of cross-border
movement of patients to Greece. Luxembourg (5%) is a
particular case because a larg e part of its insured
population is living and consuming health services in
neighbouring countries.
A smaller number of countries report figures on health
care goods and services purchased by non-residents
130
( e x p o r t s ) , t o t a l l i n g a ro u n d E U R 2 . 5 b i l l i o n i n 2 0 1 2
(Figure 6.6.2). For many countries, these figures are still
likely to be significant underestimates. Of the countries for
which data are available, France reports the highest value of
health care to foreigners at around EUR 560 million with the
Czech Republic second at close to EUR 500 million. Hungary
and Poland are also relatively high exporters in absolute
terms. Compared to overall health spending, health-related
exports remain marginal in most countries, except Croatia,
Czech Republic and Hungary where they account for 4% to
5% 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 health-related exports has
exceeded 20% per year over the past five years in Slovenia.
Patient mobility in Europe may see further growth as a
result of an EU directive, adopted in 2011 and implemented
in 2013, which supports patients in exercising their right to
cross-border health care and promotes co-operation among
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.
This category covers the purchase of medical services
and goods by resident patients while abroad.
In the balance of payments, trade refers to goods and
services transactions between residents and nonresidents 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.
6.6. TRADE IN HEALTH SERVICES
6.6.1. Imports of health care services as share of health expenditure, 2012 and annual growth rate in real terms,
2007-12 (or nearest year)
2012
Annual growth rate in real terms, 2007-12

Luxembourg
Cyprus
Netherlands
Portugal
Bulgaria1
Germany
Slovak Republic
Poland
Slovenia
Romania
Estonia
Austria
Czech Republic
Hungary
France 1
Lithuania
Italy1
Sweden
Greece
Denmark
Ireland1
United Kingdom1
5.03
3.52
1.03
1.02
0.66
0.60
0.39
0.36
0.33
0.24
0.23
0.22
0.21
0.20
0.20
0.19
0.17
0.16
0.11
0.09
0.06
0.05
30.5
8.6
1.8
-5.4
8.0
16.8
52.5
7.4
59.5
29.4
5.8
10.5
6.5
0.6
16.9
12.6
5.6
-26.1
-8.2
1.4
-3.1
Iceland
FYR of Macedonia1
Turkey1
Norway
1.02
0.70
0.49
0.23
3
2
% of current health expenditure
-16.3
10.9
8.7
63.7
16.7
-20
20
40
Annual growth rate (%)
1. Refers to Balance of Payments concept of health-related travel plus health services within personal, recreational and cultural services.
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; Eurostat Balance of Payments-International Trade in Service Statistics.
1 2 http://dx.doi.org/10.1787/888933155860
6.6.2. Exports of health-related travel or other services as share of health expenditure, 2012 and annual growth rate
in real terms, 2007-12 (or nearest year)
2012
Annual growth rate in real terms, 2007-12
5.29
Croatia
4.36
Czech Republic
Hungary
4.25
14.2
Luxembourg
2.03
23.7
Poland
1.42
14.7
Estonia
0.94
19.5
Cyprus
0.70
-7.2
Latvia
0.68
0.0
Lithuania
0.61
7.3
Slovak Republic
0.58
0.50
Bulgaria
0.47
Austria
0.30
Greece
0.28
Romania
6.1
1.0
6.0
3.3
8.6
Sweden
0.22
0.12
Italy
0.10
United Kingdom
1.5
-6.0
7.9
Turkey
1.08
10.5
Slovenia
1.58
4
3
% of current health expenditure
18.9
4.1
11.6
-20
20
40
Annual growth rate (%)
Note: Health-related exports occur when domestic providers supply medical services to non-residents.
Source: Eurostat Balance of Payments-International Trade in Service Statistics.
1 2 http://dx.doi.org/10.1787/888933155860
131

OECD 2014
Statistical annex
Table A.1. Total population, mid-year, thousands, 1960 to 2012
Austria
Belgium
Bulgaria
Croatia
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 (total)
FYR of Macedonia
Iceland
Montenegro
Norway
Serbia
Switzerland
Turkey
1960
1970
1980
1990
2000
2010
2011
2012
7 048
9 153
7 867
4 140
573
9 602
4 580
1 212
4 430
45 684
55 608
8 332
9 984
2 829
50 200
2 121
2 779
314
327
11 487
29 637
8 858
18 407
4 068
1 585
30 455
7 485
52 400
391 161
1 392
176
..
3 581
..
5 328
27 438
7 467
9 656
8 490
4 412
614
9 858
4 929
1 360
4 606
50 772
61 098
8 793
10 338
2 957
53 822
2 359
3 140
339
303
13 039
32 664
8 680
20 250
4 538
1 725
33 815
8 043
55 663
423 730
1 629
204
..
3 876
..
6 181
35 294
7 549
9 859
8 862
4 600
509
10 304
5 123
1 477
4 780
53 880
61 549
9 643
10 711
3 413
56 434
2 512
3 413
364
317
14 150
35 574
9 766
22 243
4 980
1 901
37 439
8 311
56 314
445 976
1 891
228
..
4 086
..
6 319
44 522
7 678
9 967
8 718
4 777
580
10 333
5 141
1 569
4 986
56 709
63 202 |
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
459 725
1 882
255
..
4 241
..
6 716
56 104
8 012
10 251
8 170
4 468
694
10 255
5 340
1 397
5 176
59 062
82 212
10 917
10 211
3 805
56 942
2 368
3 500
436
381
15 926
38 259
10 290
22 443
5 389
1 989
40 263
8 872
58 893
485 920
2 026
281
614
4 491
7 516
7 184
67 393
8 390
10 920
7 396
4 296
829
10 474
5 548
1 331
5 363
62 918
81 777
11 153
10 000
4 560
59 277
2 098
3 097
507
415
16 615
38 184
10 573
20 247
5 391
2 049
46 577
9 378
62 766
502 131
2 055
318
619
4 889
7 291
7 825
73 142
8 406
11 048
7 348
4 283
851
10 496
5 571
1 327
5 388
63 224
81 798
11 123
9 972
4 577
59 379
2 060
3 028
518
416
16 693
38 534
10 558
20 148
5 398
2 053
46 743
9 449
63 259
503 649
2 059
319
621
4 953
7 234
7 912
74 224
8 430
11 128
7 306
4 269
864
10 511
5 592
1 323
5 414
63 519
80 426
11 093
9 920
4 587
59 540
2 034
2 988
531
419
16 755
38 536
10 515
20 077
5 408
2 057
46 773
9 519
63 696
503 229
2 061
321
622
5 019
7 199
7 997
75 176
| Break in series.
1. Population figures for Germany prior to 1991 refer to West Germany.
1 2 http://dx.doi.org/10.1787/888933155876
133
STATISTICAL ANNEX
Table A.2. Share of the population aged 65 and over, 1 January, 1960 to 2012
1960
1970
1980
1990
2000
2010
2011
2012
Austria
12.1
14.0
15.5
14.9
15.4
17.6
17.6
17.8
Belgium
12.0
13.3
14.3
14.8
16.8
17.2
17.1
17.3
Bulgaria
7.4
9.4
11.8
13.0
16.2
18.2
18.5
18.8
Croatia
..
..
..
..
16.1
17.8
17.7
17.9
Cyprus
..
..
10.8
10.8
11.2
12.5
12.7
12.8
9.5
11.9
13.6
12.5
13.8
15.3
15.6
16.2
Denmark
10.5
12.2
14.3
15.6
14.8
16.3
16.8
17.3
Estonia
10.5
11.7
12.5
11.6
15.0
17.4
17.6
17.9
Finland
7.2
9.0
11.9
13.3
14.8
17.0
17.5
18.1
France
11.6
12.8
14.0
13.9
16.0
16.8
16.9
17.3
Germany1
10.7
13.0
15.5
15.2 |
16.2
20.7
20.6
21.0
Greece
9.4
11.1
13.1
13.7
16.5
18.9
19.3
19.7
Hungary
8.9
11.5
13.5
13.2
15.0
16.6
16.7
16.9
11.1
11.1
10.7
11.4
11.2
11.2
11.5
11.9
9.3
10.8
13.1
14.7
18.1
20.4
20.5
20.8
Latvia
..
11.9
13.0
11.8
14.8
18.1
18.4
18.6
Lithuania
..
10.0
11.3
10.8
13.7
17.3
17.9
18.1
10.8
12.5
13.7
13.4
14.3
14.0
13.9
14.0
..
..
8.4
10.4
12.1
14.9
15.7
16.4
Netherlands
8.9
10.1
11.5
12.8
13.6
15.3
15.6
16.2
Poland
5.8
8.2
10.2
10.0
12.1
13.5
13.5
13.8
Portugal
7.8
9.2
11.2
13.2
16.0
18.3
18.7
19.0
Romania
..
8.5
10.3
10.3
13.2
16.1
16.1
16.3
6.8
9.1
10.6
10.3
11.4
12.4
12.6
12.8
..
..
11.4
10.6
13.9
16.5
16.5
16.8
8.2
9.5
10.8
13.4
16.7
16.8
17.1
17.4
Sweden
11.7
13.6
16.2
17.8
17.3
18.1
18.5
18.8
United Kingdom
11.7
12.9
14.9
15.7
15.8
16.3
16.4
16.8
9.6
11.1
12.5
12.9
14.7
16.5
16.7
17.0
Czech Republic
Ireland
Italy
Luxembourg
Malta
Slovak Republic
Slovenia
Spain
EU (unweighted average)
FYR of Macedonia
Iceland
Montenegro
Norway
Serbia
Switzerland
Turkey
..
..
..
..
9.8
11.6
11.7
11.8
8.0
8.8
9.8
10.6
11.6
12.0
12.3
12.6
..
..
..
..
11.7
12.7
12.8
13.0
10.9
12.8
14.7
16.3
15.3
14.9
15.1
15.4
..
..
..
..
16.0
17.0
17.2
17.3
10.2
11.2
13.8
14.6
15.3
16.8
16.9
17.2
3.6
4.4
4.7
4.4
6.7
7.1
7.3
7.4
| Break in series.
1 2 http://dx.doi.org/10.1787/888933155887
134
STATISTICAL ANNEX
Table A.3. Crude birth rate, per 1 000 population, 1960 to 2012
1960
1970
1980
1990
2000
2010
2011
2012
Austria
17.9
15.0
12.0
11.8
9.8
9.4
9.3
9.4
Belgium
16.8
14.7
12.6
12.4
11.4
11.9
11.6
11.5
Bulgaria
17.8
16.3
14.5
12.1
9.0
10.2
9.6
9.5
Croatia
18.4
13.8
14.8
11.6
9.8
10.1
9.6
9.8
Cyprus
26.2
19.2
20.4
18.3
12.2
11.8
11.3
11.8
Czech Republic
13.4
15.0
14.9
12.6
8.9
11.2
10.4
10.3
Denmark
16.6
14.4
11.2
12.3
12.6
11.4
10.6
10.4
Estonia
16.7
15.8
15.0
14.2
9.4
11.9
11.1
10.6
Finland
18.5
14.0
13.2
13.1
11.0
11.4
11.1
11.0
France
17.9
16.7
14.9
13.4
13.1
12.8
12.5
12.4
Germany1
17.4
13.3
10.1
11.5 |
9.3
8.3
8.1
8.4
Greece
18.9
16.5
15.4
10.1
9.5
10.3
9.6
9.0
Hungary
14.7
14.7
13.9
12.1
9.6
9.0
8.8
9.1
Ireland
21.5
21.8
21.7
15.1
14.4
16.5
16.2
15.7
Italy
18.1
16.7
11.3
10.0
9.5
9.5
9.2
9.0
Latvia
16.7
14.6
14.1
14.2
8.6
9.4
9.1
9.8
Lithuania
22.5
17.7
15.2
15.4
9.8
9.9
10.0
10.2
Luxembourg
16.0
13.0
11.4
12.9
13.1
11.6
10.9
11.3
Malta
26.2
17.6
17.7
15.2
11.5
9.4
10.0
9.8
Netherlands
20.8
18.3
12.8
13.2
13.0
11.1
10.8
10.5
Poland
22.6
16.8
19.6
14.4
9.9
10.8
10.1
10.0
Portugal
24.1
20.8
16.2
11.7
11.7
9.6
9.2
8.5
Romania
19.1
21.1
17.9
13.6
10.4
10.5
9.7
10.0
Slovak Republic
21.7
17.8
19.1
15.1
10.2
11.2
11.3
10.3
Slovenia
17.6
15.9
15.7
11.2
9.1
10.9
10.7
10.7
Spain
21.7
19.5
15.3
10.3
9.9
10.4
10.1
9.7
Sweden
13.7
13.7
11.7
14.5
10.2
12.3
11.8
11.9
United Kingdom
17.5
16.2
13.4
13.9
11.5
12.9
12.8
12.8
19.0
16.5
14.9
13.1
10.7
10.9
10.6
10.5
FYR of Macedonia
31.7
23.2
21.0
18.8
14.5
11.8
11.1
11.4
Iceland
28.0
19.7
19.8
18.7
15.3
15.4
14.1
14.1
..
..
..
..
15.0
12.0
11.6
12.0
17.3
16.7
12.5
14.4
13.2
12.6
12.2
12.0
..
..
..
..
9.8
9.4
9.1
9.3
17.7
16.1
11.7
12.5
10.9
10.3
10.2
10.3
..
..
..
..
21.6
17.2
16.8
17.1
Montenegro
Norway
Serbia
Switzerland
Turkey
Note: Crude birth rate is defined as the number of live births per 1 000 population.
| Break in series.
1 2 http://dx.doi.org/10.1787/888933155898
135
STATISTICAL ANNEX
Table A.4. Fertility rate, number of children per women aged 15-49, 1960 to 2012
1960
1970
1980
1990
2000
2010
2011
2012
Austria
2.69
2.29
1.65
1.46
1.36
1.44
1.43
1.44
Belgium
2.54
2.25
1.68
1.62
1.64
1.84
1.81
1.79
Bulgaria
2.31
2.17
2.05
1.82
1.26
1.57
1.51
1.50
Croatia
2.20
1.83
1.92
1.67
1.39
1.55
1.48
1.51
Cyprus
..
..
2.48
2.41
1.64
1.44
1.35
1.39
Czech Republic
2.11
1.91
2.10
1.89
1.14
1.49
1.43
1.45
Denmark
2.54
1.95
1.55
1.67
1.77
1.88
1.76
1.73
Estonia
1.98
2.17
2.02
2.05
1.36
1.72
1.61
1.56
Finland
2.71
1.83
1.63
1.79
1.73
1.87
1.83
1.80
France
2.74
2.48
1.95
1.78
1.87
2.02
2.00
2.00
Germany1
2.37
2.03
1.56
1.45 |
1.38
1.39
1.36
1.38
Greece
2.23
2.40
2.23
1.40
1.26
1.51
1.39
1.34
Hungary
2.02
1.97
1.92
1.84
1.33
1.26
1.24
1.34
Ireland
3.76
3.87
3.23
2.12
1.90
2.06
2.06
2.02
Italy
2.41
2.43
1.68
1.36
1.26
1.41
1.39
1.42
Latvia
1.94
2.02
1.90
2.01
1.25
1.36
1.33
1.44
..
2.40
1.99
2.03
1.39
1.50
1.55
1.60
2.28
1.98
1.50
1.62
1.78
1.63
1.52
1.57
..
..
1.99
2.05
1.69
1.36
1.45
1.43
Netherlands
3.12
2.57
1.60
1.62
1.72
1.80
1.76
1.72
Poland
2.98
2.20
2.28
1.99
1.37
1.38
1.30
1.30
Portugal
3.10
2.83
2.18
1.56
1.56
1.39
1.35
1.28
Romania
2.34
2.90
2.43
1.84
1.31
1.54
1.46
1.53
Slovak Republic
3.07
2.40
2.31
2.09
1.29
1.40
1.45
1.34
Slovenia
2.18
2.21
2.11
1.46
1.26
1.57
1.56
1.58
Spain
2.86
2.90
2.22
1.36
1.23
1.37
1.34
1.32
Sweden
2.20
1.94
1.68
2.14
1.55
1.98
1.90
1.91
United Kingdom
2.72
2.43
1.90
1.83
1.64
1.93
1.91
1.92
2.54
2.32
1.99
1.78
1.48
1.59
1.55
1.56
Lithuania
Luxembourg
Malta
FYR of Macedonia
Iceland
Montenegro
Norway
Serbia
Switzerland
Turkey
..
..
..
..
1.88
1.56
1.46
1.51
4.27
2.81
2.48
2.31
2.08
2.20
2.02
2.04
..
..
..
..
..
1.69
1.65
1.71
2.91
2.50
1.72
1.93
1.85
1.95
1.88
1.85
..
..
..
..
1.48
1.40
1.40
1.45
2.44
2.10
1.55
1.59
1.50
1.54
1.52
1.53
6.2
5.6
4.6
2.9
2.5
2.1
2.0
2.1
| Break in series.
1 2 http://dx.doi.org/10.1787/888933155908
136
STATISTICAL ANNEX
Table A.5. GDP per capita in 2012 and average annual growth rates, 2000 to 2012
GDP per capita
in EUR PPP
Annual growth rate per capita in real terms
2012
2007/08
2008/09
2009/10
2010/11
2011/12
2000-12
Austria
33 130
1.0
-4.1
1.5
Belgium
30 457
0.2
-3.6
1.2
2.6
0.6
1.1
0.6
-0.9
Bulgaria
12 123
6.9
-4.9
0.6
1.1
2.5
1.2
Croatia
15 580
2.1
4.6
-6.8
-2.0
0.1
-1.9
Cyprus
23 352
2.2
1.0
-4.5
-1.3
-2.1
-3.9
Czech Republic
0.3
20 666
2.2
-5.0
2.2
1.6
-1.2
2.7
Denmark
32 118
-1.4
-6.2
0.9
0.7
-0.7
0.2
Estonia
18 450
-3.9
-13.9
2.8
9.9
4.3
4.5
Finland
29 404
-0.2
-9.0
2.9
2.3
-1.5
1.2
France
27 731
-0.6
-3.6
1.2
1.5
-0.4
0.5
Germany
32 062
1.3
-4.9
4.2
3.3
2.4
1.3
Greece
19 512
-0.4
-3.1
-4.7
-6.9
-6.7
0.3
Hungary
16 996
1.1
-6.6
1.3
1.9
-1.2
1.9
Ireland
32 913
-4.1
-7.3
-1.6
1.8
-0.1
0.7
Italy
26 223
-1.8
-5.9
1.4
0.3
-2.6
-0.2
Latvia
16 376
-1.7
-16.3
0.8
7.2
6.5
5.2
Lithuania
18 288
4.0
-13.9
3.7
8.5
5.1
5.8
Luxembourg
67 210
-2.5
-7.3
1.2
-0.3
-2.5
0.6
Malta
22 014
3.2
-3.5
3.7
1.1
0.0
0.9
Netherlands
32 541
1.4
-4.2
1.0
0.5
-1.6
0.7
Poland
17 106
5.1
1.6
3.8
3.6
1.9
3.7
Portugal
19 491
-0.2
-3.0
1.9
-1.1
-2.8
0.0
Romania
13 558
9.2
-5.8
-0.6
2.8
1.0
4.7
Slovak Republic
19 404
5.7
-5.1
4.3
2.9
1.6
4.4
Slovenia
21 382
3.2
-8.8
0.8
0.5
-2.7
1.8
Spain
24 129
-0.7
-4.7
-0.7
-0.3
-1.7
0.3
Sweden
32 186
-1.4
-5.8
5.7
2.2
0.2
1.5
United Kingdom
26 638
-1.5
-5.9
0.9
0.3
-0.4
0.8
EU28 (unweighted)
25 037
1.0
-6.2
1.3
1.7
-0.3
1.9
EU28 (weighted)1
25 656
0.0
-4.8
1.8
1.3
-0.3
1.0
FYR of Macedonia
9 044
4.8
-1.1
2.7
2.6
-0.5
2.2
Iceland
29 372
-0.7
-6.9
-4.0
2.3
0.9
1.0
Montenegro
10 346
6.5
-6.1
4.5
3.0
-2.8
3.8
Norway
49 663
-1.2
-2.9
-0.8
0.0
1.6
0.6
Serbia
9 039
4.3
-3.1
1.4
2.4
-1.0
3.2
Switzerland
39 939
0.9
-3.2
1.9
0.7
0.0
0.8
Turkey
13 711
-0.6
-6.1
7.5
7.2
0.8
3.2
1. The weighted average is calculated based on total GDP divided by the total population of the 28 EU member states.
1 2 http://dx.doi.org/10.1787/888933155912
137
STATISTICAL ANNEX
Table A.6. Total expenditure on health per capita in 2012 and average annual growth rates,
2000 to 2012
Total health
expenditure
per capita in
EUR PPP
Annual growth rate per capita in real terms1
2012
2007/08
2008/09
2009/10
2010/11
2011/12
2000-12
(or latest year)
Austria
3 676
3.2
2.1
1.1
0.3
2.7
2.0
Belgium3
3 318
3.5
3.3
0.3
1.1
1.8
3.1
900
9.5
-1.5
6.0
-1.8
3.3
6.2
Croatia
1 133
5.8
-6.9
-1.0
-7.7
-2.0
1.6
Cyprus
1 728
15.0
2.6
-3.0
2.0
-6.2
2.4
Czech Republic
1 560
6.9
9.2
-3.2
2.6
-0.5
4.2
Denmark
3 528
0.6
5.7
-2.5
-1.3
0.3
2.1
Estonia
1 086
12.8
-1.5
-6.3
1.3
5.4
5.5
Finland
2 672
3.1
0.5
0.9
1.8
0.1
3.2
France
3 220
0.6
2.4
0.8
1.3
0.3
1.7
Germany
3 613
3.5
4.4
2.4
0.6
2.6
2.0
Greece
1 809
2.8
-2.5
-11.3
-3.9
-11.7
1.6
Hungary
1 354
-1.7
-3.2
5.5
1.5
-2.0
2.7
Ireland
2 921
9.6
2.6
-8.9
-3.7
1.8
3.7
Italy
2 409
2.7
-0.5
1.5
-1.4
-3.3
1.1
934
-7.1
-13.7
-4.7
1.2
-0.4
4.8
Lithuania
1 219
10.4
-1.8
-2.4
4.9
2.1
6.1
Luxembourg
3 437
4.8
1.4
-4.9
-5.5
-5.0
-0.8
Malta
1 921
-0.3
-1.4
3.1
4.2
2.0
3.3
Netherlands3
3 829
3.9
3.4
2.8
0.7
3.1
4.4
Poland
1 156
14.3
6.4
1.1
1.3
0.3
5.5
Portugal3
1 845
3.0
2.9
1.0
-5.9
-4.8
0.8
Romania
753
13.2
-1.8
4.4
-3.2
0.1
6.8
Slovak Republic
1 580
9.3
8.3
-3.0
-3.8
4.0
7.8
Slovenia
2 003
9.5
1.1
-2.5
0.6
0.4
2.9
Spain
2 243
4.4
2.5
-0.1
-2.4
-3.3
2.4
Sweden
3 083
2.1
1.4
0.7
2.4
1.1
2.9
United Kingdom
2 470
3.3
4.3
-2.8
-1.2
0.0
3.3
EU28 (unweighted)
2 193
5.3
1.1
-0.9
-0.5
-0.3
3.3
EU28 (weighted)2
2 535
3.3
3.2
0.3
-0.2
0.0
2.4
FYR of Macedonia
651
4.1
-1.8
3.8
2.4
3.1
0.6
2 655
-0.2
-1.8
-7.4
-0.4
0.8
0.6
783
-2.9
-6.5
18.7
3.3
2.3
3.8
4 610
2.7
1.6
-1.4
3.3
2.2
2.5
957
4.3
-2.0
3.9
-1.5
1.4
6.4
4 565
1.7
3.5
1.1
2.0
3.4
2.0
739
0.0
-6.1
-0.7
1.0
2.8
3.9
Bulgaria
Latvia
Iceland
Montenegro
Norway
Serbia
Switzerland
Turkey
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 28 EU member states.
3. Data refer to current health expenditure (excluding investment).
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; Eurostat Statistics Database; WHO Global Health Expenditure
Database.
1 2 http://dx.doi.org/10.1787/888933155920
138
STATISTICAL ANNEX
Table A.7. Total expenditure on health, percentage of GDP, 1980 to 2012

1980
1990
2000
2005
2010
2011
2012
10.0
Austria
7.5 |
8.4
10.4
11.1
10.9
11.1
Belgium2
6.3
7.2
8.1 |
9.6
10.6
10.6
10.9
Bulgaria
..
..
6.2 |
7.3
7.6
7.3
7.4
Croatia
..
..
7.8
7.0
7.9 |
7.3
7.2
Cyprus
..
..
5.8 |
6.4
7.3
7.6
7.4
Czech Republic
..
4.4 |
6.3 |
6.9
7.4
7.5
7.5
8.3
8.7 |
9.8
11.1
10.9
11.0
5.9
Denmark
8.9
Estonia
..
..
5.3
5.0
6.3
5.8
Finland
6.3
7.7 |
7.2
8.4
9.0
8.9
9.1
France
7.0
8.4 |
10.1 |
10.9
11.6
11.5
11.6
Germany
8.4
8.3 |
10.4
10.8
11.6
11.2
11.3
Greece
5.9
6.7
8.0
9.7
9.5
9.8
9.3
..
..
7.2 |
8.4
8.1
8.0
8.0
8.1
6.0
6.2
7.6
9.2
8.7
8.9
Italy
..
7.7
7.9
8.7
9.4
9.2
9.2
Latvia
..
..
6.0 |
6.3
6.5
6.1
5.7
Lithuania
..
..
6.5 |
5.8
7.1
6.9
6.7
5.4 |
7.5
7.9
7.6
7.3
7.1
..
6.6
9.1
8.5
8.7
9.1
7.6 |
10.1
11.2
11.2
11.8
4.8
5.5 |
6.2
7.0
6.9
6.8
5.6 |
8.6
9.8
10.2
9.7
9.5
Hungary
Ireland
Luxembourg
Malta
Netherlands2
Poland
5.2
..
7.0
..
7.5 |
Portugal2
4.9
Romania
..
..
4.3 |
5.5
5.9
5.6
5.6
Slovak Republic
..
..
5.5
7.0 |
8.5
8.0
8.1
Slovenia
..
..
8.3 |
8.5
9.1
9.1
9.4
Spain
5.3
6.5 |
7.2 |
8.3
9.6
9.4
9.3
Sweden
8.7
8.1 |
8.2
9.1
9.5
9.5
9.6
United Kingdom
5.6
5.8
6.9
8.1
9.4
9.2
9.3
EU28 (unweighted)
..
..
7.3
8.2
8.8
8.7
8.7
EU28 (weighted)1
..
..
8.5
9.4
10.2
10.1
10.1
FYR of Macedonia
..
..
8.7
8.1
7.0
6.9
7.1
6.3
7.8
9.5
9.4
9.3
9.0
9.0
..
..
7.5
8.7
7.2
7.2
7.6
7.0
7.6
8.4
9.0
9.4
9.3
9.3
..
..
7.4
9.1
10.7
10.3
10.5
Iceland
Montenegro
Norway
Serbia
Switzerland
7.2
8.0 |
9.9
10.9
10.9
11.1
11.4
Turkey
2.4
2.7 |
4.9
5.4
5.6
5.3
5.4
| Break in series.
1. The weighted average is calculated based on total health spending divided by total GDP of the 28 EU member states.
2. Data refer to current health expenditure (excluding investment).
Source: OECD Health Statistics 2014, http://dx.doi.org/10.1787/health-data-en; Eurostat Statistics Database; WHO Global Health Expenditure
Database.
1 2 http://dx.doi.org/10.1787/888933155930
139
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(81 2014 21 1 P) ISBN 978-92-64-22327-1 2014

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Health at a Glance:

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ISBN 978-92-64-22327-1 (print)

Series: Health at a Glance: Europe

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Corrigenda to OECD publications may be found on line at: www.oecd.org/about/publishing/corrigenda.htm.

HEALTH AT A GLANCE: EUROPE 2014 OECD 2014

Chapter 1. Health status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.3. Mortality from all causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.14. Diabetes prevalence and incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter 2. Determinants of health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter 3. Health care resources and activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HEALTH AT A GLANCE: EUROPE 2014 OECD 2014

Chapter 4. Quality of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.5. Procedural or postoperative complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Chapter 6. Health expenditure and financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Statistical annex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

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HEALTH AT A GLANCE: EUROPE 2014 OECD 2014

Health at a Glance: Europe 2014

Life expectancy has continued to increase, but inequalities persist

Assessing the impact of the economic crisis on health

Health spending has fallen or slowed following the economic crisis

Universal health coverage has protected access to health care

Quality of care has improved in most countries, but disparities persist

HEALTH AT A GLANCE: EUROPE 2014 OECD 2014

Structure of the publication

Data and limitations

HEALTH AT A GLANCE: EUROPE 2014 OECD 2014

Country ISO codes

HEALTH AT A GLANCE: EUROPE 2014 OECD 2014

Health at a Glance: Europe 2014

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.8. Infant mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.9. Infant health: Low birth weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.10. Self-reported health and disability . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.11. Incidence of selected communicable diseases . . . . . . . . . . . . . . . . . .

1.13. Cancer incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.14. Diabetes prevalence and incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.15. Dementia prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.1. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT BIRTH

Life expectancy at birth continues to increase in European

in their usual activities. For men, the proportion of life in

Definition and comparability

HEALTH AT A GLANCE: EUROPE 2014 OECD 2014

1.1. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT BIRTH

1.1.1. Life expectancy at birth, 1990 and 2012

Source: Eurostat Statistics Database.

HEALTH AT A GLANCE: EUROPE 2014 OECD 2014

1.2. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT AGE 65

Life expectancy at age 65 has increased significantly

65-year-old men with a high level of education can expect

Definition and comparability

HEALTH AT A GLANCE: EUROPE 2014 OECD 2014

1.2. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT AGE 65

Source: Eurostat Statistics Database.