Health at a Glance: Europe

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This biennial publication presents a set of key indicators of health status, determinants of health, health care resources and activities, quality of care, health expenditure and financing in 35 European countries, including the 27 European Union member states, 5 candidate countries and 3 EFTA countries. The selection of indicators is based largely on the European Community Health Indicators (ECHI) shortlist, a set of indicators that has been developed to guide the reporting of health statistics in the European Union.  It is complemented by additional indicators on health expenditure and quality of care, building on the OECD expertise in these areas. Each indicator is presented in a user-friendly format, consisting of charts illustrating variations across countries and over time, a brief descriptive analysis highlighting the major findings conveyed by the data, and a methodological box on the definition of the indicator and any limitations in data comparability.

Health at a Glance: Europe 2012

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16 nov 2012
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This second edition of Health at a Glance: Europe presents a set of key indicators of health status, determinants of health, health care resources and activities, quality of care, health expenditure and financing in 35 European countries, including the 27 European Union member states, 5 candidate countries and 3 EFTA countries. The selection of indicators is based largely on the European Community Health Indicators (ECHI) shortlist, a set of indicators that has been developed to guide the reporting of health statistics in the European Union.  It is complemented by additional indicators on health expenditure and quality of care, building on the OECD expertise in these areas. Each indicator is presented in a user-friendly format, consisting of charts illustrating variations across countries and over time, a brief descriptive analysis highlighting the major findings conveyed by the data, and a methodological box on the definition of the indicator and any limitations in data comparability.

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  • Foreword

    This second edition of Health at a Glance: Europe presents the most recent key indicators of health and health systems across 35 countries: the 27 European Union member states, five candidate countries and three European Free Trade Association countries. The report comes at a difficult time for European health systems. The economic crisis is increasing poverty, unemployment and stress, all of which are associated with worse health outcomes, yet public and private budgets are under great strain. The report highlights the marked slowdown (sometimes even reduction) in health spending over recent years in many countries, as part of broader efforts to reduce large budgetary deficits. If the report does not yet show any worsening health outcomes due to the crisis, there is no cause for complacency – it takes time for poor social conditions or poor quality care to take its toll from people’s health. Policy makers have often done what they could to ensure that access to high quality care remains the norm in Europe; whether this is enough to protect the health of the population will only become clear in years to come.

  • Executive summary

    European countries have achieved major gains in population health in recent decades. Life expectancy at birth in European Union (EU) member states has increased by more than six years since 1980, to reach 79 years in 2010, while premature mortality has reduced dramatically. Over three-quarters of these years of life can be expected to be lived free of activity limitation. Gains in life expectancy can be explained by improved living and working conditions and some health-related behaviours, but better access to care and quality of care also deserves much credit, as shown, for instance, by sharply reduced mortality rates following a heart attack or stroke.

  • Introduction

    Health at a Glance: Europe 2012 presents key indicators of health and health systems in 35 European countries, including the 27 European Union member states, 5 candidate countries and 3 European Free Trade Association countries. The selection of indicators is based largely on the European Community Health Indicators (ECHI) shortlist, a set of indicators that has been developed to guide the reporting of health statistics in the European Union (ECHIM, 2012). It is complemented by additional indicators on health expenditure and quality of care in the related chapters.

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  • Ouvrir / Fermer Cacher / Voir les résumés Health status

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    • Life expectancy and healthy life expectancy at birth

      Life expectancy at birth continues to increase in European countries, reflecting reductions in mortality rates at all ages. These gains in longevity can be attributed to a number of factors, including rising living standards, improved lifestyle and better education, as well as greater access to quality health services. Better nutrition, sanitation and housing also play a role, particularly in countries with developing economies (OECD, 2011b).

    • 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.

    • Mortality from all causes

      Statistics on deaths remain one of the most widely available and comparable sources of information on health. Registering deaths is compulsory in all European countries, and the data collected through the process of registration can be used by statistical and health authorities to monitor diseases and health status, and to plan health services. In order to compare levels of mortality across countries and over time, the data need to be standardised to remove the effect of differences in age structure.

    • Mortality from heart disease and stroke

      Cardiovascular diseases are the main cause of mortality in almost all EU member states, accounting for 36% of all deaths in the region in 2010. They cover a range of diseases related to the circulatory system, including ischemic heart disease (known as IHD, or heart attack) and cerebro-vascular disease (or stroke). Together, IHD and stroke comprise 60% of all cardiovascular deaths, and caused more than one-fifth of all deaths in EU member states in 2010.

    • Mortality from cancer

      Cancer is the second leading cause of mortality in EU member states after diseases of the circulatory system, accounting for 28% of all deaths in 2010. In 2010, cancer mortality rates were the lowest in Cyprus, Finland and Sweden, as well as Switzerland, at under 150 deaths per 100 000 population. They were the highest in central European countries, including the Czech Republic, Hungary, Poland, the Slovak Republic and Slovenia, at close to or above 200 deaths per 100 000 population.

    • Mortality from transport accidents

      Injuries from transport accidents – most of which are due to road traffic – are a major public health problem in the European Union, causing the premature deaths of some 40 000 people every year. In addition to these deaths, more than 1.5 million people are estimated to be so seriously injured as to require hospital admission each year (OECD/ITF, 2011a). Around 4 000-5 000 transport accident deaths occurred in each of France, Germany, Italy and Poland in 2010.

    • Suicide

      The intentional killing of oneself can be seen as evidence not only of personal breakdown, but also of a deterioration of the social context in which an individual lives. Suicide may be the end-point of a number of different contributing factors. It is more likely to occur during crisis periods associated with upheavals in personal relationships, through alcohol and drug abuse, unemployment, clinical depression and other forms of mental illness. Because of this, suicide is often used as a proxy indicator of the mental health status of a population. However, the number of suicides in certain countries may be under-reported because of the stigma that is associated with the act, or because of data issues associated with reporting criteria (see Definition and comparability).

    • 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.

    • 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).

    • Self-reported health and disability

      Most European countries conduct regular health surveys which allow respondents to report on different aspects of their health. A commonly-asked question relates to self-perceived health status, of the type: How is your health in general?. Despite the subjective nature of this question, indicators of perceived general health have been found to be a good predictor of people’s future health care use and mortality (DeSalvo et al., 2005; Bond et al., 2006).

    • Incidence of selected communicable diseases

      Communicable diseases such as chlamydia, pertussis and hepatitis B still pose major threats to the health of European citizens. Chlamydia is the most common sexually transmitted infection in Europe. Three-quarters of all cases are reported among young people aged 15-24 years, and numbers are steadily increasing. It can be controlled through prevention, reducing risk behaviour, early detection and effective management. Pertussis (or whooping cough) is highly infectious, and is caused by the bacterium Bordetella pertussis. The disease derives its name from the sound made from the intake of air after a cough. Hepatitis B is an infection of the liver caused by the hepatitis B virus. The virus is transmitted by contact with blood or body fluids of an infected person. A small proportion of infections become chronic, and these people are at high risk of death from cancer or cirrhosis of the liver. Protection against pertussis and hepatitis B is available through vaccination (see Childhood vaccination programmes).

    • HIV/AIDS

      The first cases of Acquired Immunodeficiency Syndrome (AIDS) were diagnosed more than 30 years ago. The onset of AIDS is caused as a result of HIV (human immunodeficiency virus) infection and can manifest itself as any number of different diseases, such as pneumonia and tuberculosis, as the immune system is no longer able to defend the body, leaving it susceptible to opportunistic infections and tumors. There is a time lag between HIV infection, AIDS diagnosis and death, which can be any number of years depending on the treatment administered. Despite worldwide research, there is no cure currently available. HIV remains a major public health issue in Europe, with continuing transmission.

    • Cancer incidence

      In 2008, an estimated 2.4 million new cases of cancer (excluding non-melanoma skin cancers) were diagnosed in EU member states (Ferlay et al., 2010), and of these 55% occurred among males and 45% among females. The most commonly diagnosed cancers were prostate, colorectal, breast and lung cancer. The risk of getting cancer before the age of 75 years was 26.5%, or around one in four. However, because the population of Europe is ageing, the rate of new cases of cancer is also expected to increase (EC, 2008b).

    • Diabetes prevalence and incidence

      Diabetes is a chronic metabolic disease, characterised by high levels of glucose in the blood. It occurs either because the pancreas stops producing the hormone insulin (Type 1 diabetes), or through a combination of the pancreas having reduced ability to produce insulin alongside the body being resistant to its action (Type 2 diabetes). People with diabetes are at a greater risk of developing cardiovascular diseases such as heart attack and stroke if the disease is left undiagnosed or poorly controlled. They also have elevated risks for sight loss, foot and leg amputation due to damage to the nerves and blood vessels, and renal failure requiring dialysis or transplantation.

    • Dementia prevalence

      Dementia describes a variety of brain disorders which progressively lead to brain damage, and cause a gradual deterioration of the individual’s functional capacity and social relations. It is one of the most important causes of disability among the elderly, placing a large burden not only on sufferers, but also on carers. Alzheimer’s disease is the most common form of dementia, representing about 60% to 80% of cases. Successive strokes that lead to multi-infarct dementia are another common cause. Currently, there is no treatment that can halt dementia, but pharmaceutical drugs and other interventions can help treat symptoms.

    • Asthma and COPD prevalence

      Asthma is a disease of the bronchial tubes characterised by wheezing during breathing, shortness of breath or coughing. Asthma is the single most common chronic disease among children, and also affects many adults. It is a significant public health problem and a high-burden disease for which prevention is partly possible and treatment can be effective. Its causes are not well understood, but effective medicines are available to help in maintaining quality of life and avoiding disability and death (The Union/ISAAC, 2011).

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    • Smoking and alcohol consumption among children

      Regular smoking or excessive drinking in adolescence has both immediate and long-term health consequences. Children who establish smoking habits in early adolescence increase their risk of cardiovascular diseases, respiratory illnesses and cancer. They are also more likely to experiment with alcohol and other drugs. Alcohol misuse is itself associated with a range of social, physical and mental health problems, including depressive and anxiety disorders, obesity and accidental injury (Currie et al., 2012).

    • Overweight and obesity among children

      Children who are overweight or obese are at greater risk of poor health in adolescence and also in adulthood. Among young people, orthopaedic problems and psychosocial problems such as low self-image, depression and impaired quality of life can result from overweight. Excess weight problems in childhood are associated with an increased risk of being an obese adult, at which point cardiovascular disease, diabetes, certain forms of cancer, osteoarthritis, a reduced quality of life and premature death become health concerns (Sassi, 2010; Currie et al., 2012).

    • Fruit and vegetable consumption among children

      Nutrition is important for children’s development and long-term health. Eating fruit during adolescence, for example, in place of high-fat, sugar and salt products, can protect against health problems such as obesity, diabetes, and heart problems. Moreover, eating fruit and vegetables when young can be habit forming, promoting healthy eating behaviours for later life.

    • Physical activity among children

      Undertaking physical activity in adolescence is beneficial for health, and can set standards for adult physical activity levels, thereby influencing health outcomes in later life. Research supports the role that physical activity has in child and adolescent development, learning and well-being, and in the prevention and treatment of a range of youth health issues including asthma, mental health, bone health and obesity. More direct links to adult health are found between physical activity in adolescence and its effect on overweight and obesity and related diseases, breast cancer rates and bone health in later life. The health effects of adolescent physical activity are sometimes dependent on the activity type, e.g. water physical activities in adolescence are effective in the treatment of asthma, and exercise is recommended in the treatment of cystic fibrosis (Hallal et al., 2006; Currie et al., 2012).

    • Smoking among adults

      Tobacco is responsible for about one-in-ten adult deaths worldwide, equating to about 5 million deaths each year (WHO, 2012a). It is a major risk factor for at least two of the leading causes of premature mortality – circulatory disease and cancer, increasing the risk of heart attack, stroke, lung cancer, cancers of the larynx and mouth, and pancreatic cancer. Smoking also causes peripheral vascular disease and hypertension. In addition, it is an important contributory factor for respiratory diseases such as chronic obstructive pulmonary disease (COPD), while smoking among pregnant women can lead to low birth weight and illnesses among infants. It remains the largest avoidable risk to health in European countries.

    • Alcohol consumption among adults

      The health burden related to excessive alcohol consumption, both in terms of morbidity and mortality, is considerable (Rehm et al., 2009; WHO Europe, 2012a). In Europe, alcohol is the third leading risk factor for disease and mortality after tobacco and high blood pressure. High alcohol intake is associated with increased risk of heart, stroke and vascular diseases, as well as liver cirrhosis and certain cancers. Foetal exposure to alcohol increases the risk of birth defects and intellectual impairments. Alcohol also contributes to death and disability through accidents and injuries, assault, violence, homicide and suicide. It is, however, one of the major avoidable risk factors.

    • Overweight and obesity among adults

      The growth in overweight and obesity rates among adults is a major public health concern. Obesity is a known risk factor for numerous health problems, including hypertension, high cholesterol, diabetes, cardiovascular diseases, respiratory problems (asthma), musculoskeletal diseases (arthritis) and some forms of cancer. Mortality also increases sharply once the overweight threshold is crossed (Sassi, 2010). Because obesity is associated with higher risks of chronic illnesses, it is linked to significant additional health care costs.

    • Fruit and vegetable consumption among adults

      Nutrition is an important determinant of health. Inadequate consumption of fruit and vegetables is one factor that can play a role in increased morbidity. Proper nutrition assists in preventing a number of obesity-related chronic conditions, including cardiovascular disease, hypertension, Type 2 diabetes, stroke, certain cancers, musculoskeletal disorders and a range of mental health conditions. A European Commission White Paper advocated increasing the consumption of fruit and vegetables as one of a number of tools to offset a worsening trend of poor diets and low physical activity (EC, 2007).

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    • Medical doctors

      In many European countries, there are concerns about current or future shortages of doctors, in general or more specifically for certain categories of doctors or in certain locations (e.g. in rural and remote areas). This section provides data on the number of doctors per capita in European countries in 2010 and its evolution over the past decade, as well as a disaggregation between generalists and specialists.

    • Consultations with doctors

      Consultations with doctors can take place in doctors’ offices or clinics, in hospital outpatient departments or, in some cases, in patients’ own homes. In many European countries (e.g. Denmark, Italy, the Netherlands, Norway, Portugal, the Slovak Republic, Spain and the United Kingdom), patients are required or given incentives to consult a general practitioner (GP) about any new episode of illness. The GP may then refer them to a specialist, if indicated. In other countries (e.g. Austria, the Czech Republic and Iceland), patients may approach specialists directly.

    • Nurses

      Nurses are usually the most numerous health profession, outnumbering physicians in most European countries. Nurses play a critical role in providing health care not only in traditional settings such as hospitals and long-term care institutions but increasingly in primary care (especially in offering care to the chronically ill) and in home care settings. However, there are concerns in many countries about shortages of nurses, and these concerns may well intensify in the future as the demand for nurses continues to increase and the ageing of the baby boom generation precipitates a wave of retirements among nurses. These concerns have prompted many countries to increase the training of new nurses combined with efforts to increase the retention of nurses in the profession (OECD, 2008a).

    • Medical technologies: CT scanners and MRI units

      New medical technologies are improving diagnosis and treatment, but they are also increasing health spending. This section presents data on the availability and use of two diagnostic technologies: computed tomography (CT) scanners and magnetic resonance imaging (MRI) units. CT scanners and MRI units help physicians diagnose a range of conditions by producing images of internal organs and structures of the body. Unlike conventional radiography and CT scanning, MRI exams do not expose patients to ionising radiation.

    • 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 same-day emergency or elective interventions.

    • Hospital discharges

      Hospital discharges measure the number of people who were released after staying at least one night in hospital. Together with the average length of stay, they are important indicators of hospital activities. Hospital activities are affected by a number of factors, including the capacity of hospitals to treat patients, the ability of the primary care sector to prevent avoidable hospital admissions, and the availability of post-acute care settings to provide rehabilitative and long-term care services.

    • Average length of stay in hospitals

      The average length of stay in hospitals is often regarded as an indicator of efficiency, since a shorter stay may reduce the cost per discharge and shift care from inpatient to less expensive post-acute settings. However, shorter stays tend to be more service intensive and more costly per day. Too short a length of stay could also have adverse effects on health outcomes, or reduce the comfort and recovery of the patient. If this leads to a rising readmission rate, costs per episode of illness may fall little, or even rise.

    • Cardiac procedures (coronary angioplasty)

      Heart diseases are a leading cause of hospitalisation and death in European countries (see ). Coronary angioplasty is a procedure that has revolutionised the treatment of ischemic heart diseases over the past twenty years, involving the use of a minimally invasive technique to re-open the obstructed coronary arteries rather than an open-chest bypass surgery. The placement of a stent to keep the artery open accompanies the majority of angioplasties.

    • Cataract surgeries

      In the past two decades, the number of surgical procedures carried out on a same-day basis, without any need for hospitalisation, has grown in European countries. Advances in medical technologies, particularly the diffusion of less invasive surgical interventions, and better anaesthetics have made this development possible. These innovations have also improved patient safety and health outcomes for patients, and have in many cases reduced the unit cost per intervention by shortening the length of stay in hospitals. However, the impact of the rise in same-day surgeries on health spending depends not only on changes in their unit cost, but also on the growth in the volume of procedures performed. There is also a need to take into account any additional cost related to post-acute care and community health services following the intervention.

    • Hip and knee replacement

      Significant advancements in surgical treatment have provided effective options to reduce the pain and disability associated with certain musculoskeletal conditions. Joint replacement surgery (hip and knee replacement) is considered the most effective intervention for severe osteoarthritis, reducing pain and disability and restoring some patients to near normal function.

    • Pharmaceutical consumption

      The consumption of pharmaceuticals has increased over the past decade not only in terms of expenditure (see Pharmaceutical expenditure), but also in terms of the volume or quantity of medicines consumed. This section reviews trends in the volume of consumption of three categories of pharmaceuticals: antibiotics, antidiabetics and antidepressants. Consumption of these medicines is measured through the defined daily dose (DDD) unit, as recommended by the WHO Collaborating Center for Drug Statistics (see the box on Definition and comparability).

    • 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.

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    • Avoidable admissions: Respiratory diseases

      Both asthma and chronic obstructive pulmonary disease (COPD) are, to a considerable degree, either preventable or manageable through proper prevention or primary care interventions. Proper management of these chronic conditions in primary care settings can reduce exacerbation and costly hospitalisation (Menn et al., 2012). Hospital admission rates serve as a proxy for primary care quality, whereby high admission rates may point to poor care co-ordination or care continuity. They may also indicate structural constraints such as an inadequate supply of family physicians (Rosano et al., 2012).

    • Avoidable admissions: Uncontrolled diabetes

      The health and economic burden of diabetes continues to rise. Across the European Union there are an estimated 31 million adults living with diabetes and many people remain undiagnosed (Mladovsky et al., 2009). Diabetes leads to an increased risk of cardiovascular disease, blindness, kidney disease, lower limb amputation and mortality. Across Europe, the treatment and management of diabetes has been estimated to account for approximately 10% of total health care expenditure (Zhang et al., 2010).

    • In-hospital mortality following acute myocardial infarction

      Care for AMI (heart attack) has changed dramatically in recent decades (Khush et al., 2005; Gil et al., 1999). Clinical practice guidelines, such as those developed by the European Society of Cardiology, provide clinicians with the best available evidence on how to optimise care. Numerous studies have shown that greater compliance with guidelines improves health outcomes (e.g. Schiele et al., 2005; Eagle et al., 2005). However, a considerable proportion of AMI patients do not receive recommended care (Brekke and Gjelsvik, 2009; Kotseva et al., 2009).

    • In-hospital mortality following stroke

      In Europe, stroke and other cerebrovascular diseases account for around 9% of all deaths and are the third most common cause of death (OECD, 2012a, based on the WHO Mortality Database). Stroke is also a major cause of adult disability. Around one third of all stroke incidents lead to permanent sequelae and dependency (WHO, 2004b). In ischemic stroke, representing about 85% of cases, the blood supply to a part of the brain is interrupted, leading to a necrosis of the affected part, while in hemorrhagic stroke, the rupture of a blood vessel causes bleeding into the brain, usually causing more widespread damage.

    • Procedural or postoperative complications

      Several European studies have documented that between 8% and 12% of patients admitted to hospitals suffer from adverse effects whilst receiving health care (UK Department of Health, 2000; WHO Europe, 2012b). The European Commission estimates that without any policy changes, there are likely to be 10 million adverse events related to hospitalisations (including infection-related ones) in the European Union per year, of which almost 4.4 million would be preventable (EC, 2008d).

    • Obstetric trauma

      The patient safety indicators related to obstetric trauma flag cases of potentially preventable third- and fourth-degree perineal tears during vaginal delivery. Such tears extending to the perineal muscles, anal sphincter and bowel wall require surgical treatment after birth. Possible complications include continued perineal pain and anal incontinence. A recent study found that around 10% of women who had such tears will suffer from faecal incontinence initially (compared to 3% of women who do not have a tear). Almost 45% of women with initial symptoms had remaining problems after four to eight years (Sundquist, 2012).

    • Screening, survival and mortality for cervical cancer

      Cervical cancer is mainly the outcome of persistent infection with human papillomavirus (HPV), which accounts for approximately 95% of all cases (IARC, 1995; Franco et al., 1999). Every year 61 000 new cervical cancers are diagnosed in Europe (IARC, 2011).

    • Screening, survival and mortality for breast cancer

      Breast cancer is the most prevalent form of cancer among women, with 425 000 new cases diagnosed each year in Europe (IARC, 2011). Risk factors that increase a person’s chance of getting this disease include, but are not limited to, age, family history of breast cancer, oestrogen replacement therapy and alcohol. Annual incidence in Europe is expected to rise to 466 000 cases by 2020. Variation in breast cancer care across European countries is indicated by mammography screening rates in women aged 50-69 years, relative survival rates, and mortality rates.

    • Screening, survival and mortality for colorectal cancer

      Colorectal cancer is the most commonly diagnosed form of cancer in Europe, with over 432 000 new cases diagnosed each year. By 2020, annual incidence is expected to rise to 502 000 cases (IARC, 2011). The annual incidence rate varies from 21 new cases per 100 000 population in Greece to 64 new cases in the Czech Republic. There are several factors that place certain individuals at increased risk for the disease, including age, the presence of polyps, ulcerative colitis, a diet high in fat and genetic background. Furthermore, males are at higher risk of developing colorectal cancer than females (IARC, 2011).

    • Childhood vaccination programmes

      All EU member states have established childhood vaccination programmes. All programmes include vaccinations against diseases such as pertussis, diphtheria, tetanus and measles. Reviews of the evidence supporting the efficacy of vaccines against these diseases have concluded that the respective vaccines are safe and highly effective. For example, Peltola et al. (1994) reported that 12 years after the introduction of a comprehensive national vaccination programme in Finland measles had virtually been eradicated. Numerous studies have also shown that childhood vaccines can be highly cost-effective (e.g. Beutels and Gay, 2003; Banz et al., 2003; Lieu et al., 1994).

    • Influenza vaccination for older people

      Influenza is a common infectious disease and affects people of all ages. WHO Europe reports that each year seasonal influenza affects between 5 to 15% of the population in the northern hemisphere. Most people with the illness recover quickly, but elderly people and those with chronic medical conditions are at higher risk of complications and even death. In any particular year, influenza can have a substantial impact on the health of the population and the health care system (Nicholson et al., 2003; Simonsen et al., 2000).

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    • Coverage for health care

      Health care coverage enables access to medical goods and services and provides financial security against unexpected or serious illness. However, the share of the population with health insurance coverage – be it public or private – is an imperfect indicator of accessibility, since the range of services covered and the degree of cost-sharing applied to those services vary across countries.

    • Health expenditure per capita

      There are large variations in the level and in the rate of growth of health spending across European countries.

    • Health expenditure in relation to GDP

      In 2010, EU member states devoted on average (unweighted) 9.0% of their GDP to health spending in 2010 (), up significantly from 7.3% in 2000, but down slightly from the peak of 9.2% reached in 2009 following the economic crisis which started in many countries in the middle of 2008. In many countries, public spending on health was maintained in 2009 while GDP was falling strongly, but this was followed in 2010 by the implementation of a range of measures to reduce government health spending as part of broader efforts to reduce large budgetary deficits and debts (see ).

    • Health expenditure by function

      In 2010, curative and rehabilitative care provided either as inpatient care (including day care) or outpatient care, accounted for 61% of current health spending (excluding capital investment) on average across EU member states (). A further 23% of health spending was allocated to medical goods (including mainly pharmaceuticals, which accounted for 19% of total health spending), 10% to long-term care and the remaining 6% on collective services including public health services and administration.

    • Pharmaceutical expenditure

      Pharmaceutical expenditure accounted for almost a fifth (19%) of all health expenditure on average in EU member states in 2010, making it the third biggest spending component after inpatient and outpatient care. Increased spending on pharmaceuticals has contributed to the overall rise in total health expenditure over the past decade, although the growth rate turned negative in several countries in 2010. The relationship between pharmaceutical expenditure and other health expenditure is a complex one, in that increased expenditure on pharmaceuticals to tackle different diseases may reduce the need for costly hospitalisations and interventions now or in the future.

    • Financing of health care

      All European countries use a mix of public and private financing to pay for health care. In some countries, public purchasing of health care is generally confined to the use of government revenues. In others where there is social insurance, public financing uses these social contributions, in addition to any general government revenues. Private financing of health care consists of payments by households (either as stand-alone payments or co-payments) as well as various forms of private health insurance intended to replace, complement or supplement publicly financed coverage. In addition, occupational health care may be directly provided by employers, and other health care benefits may be provided by charities and other non-government organisations.

    • Trade in health services

      Trade in health services and its most high-profile component, medical tourism, has attracted a great deal of media attention in recent years. The growth in imports and exports has been fuelled by a number of factors. Technological advances in information systems and communication allow patients or third party purchasers of health care to seek out quality treatment at lower cost and/or more immediately from health care providers in other countries. An increase in the portability of health cover, whether as a result of regional arrangements with regard to public health insurance systems, or developments in the private insurance market, are also poised to further increase patient mobility. All this is coupled with a general increase in the temporary movement of populations for business, leisure or specifically for medical purposes between countries.

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