Archive:Healthcare expenditure statistics

Data extracted in September 2016. Most recent data: Further Eurostat information, Main tables and Database. Planned article update: September 2017.

This article presents key statistics on expenditure and financing aspects of healthcare in the European Union (EU); these data complement data on healthcare provision. Healthcare systems are organised and financed in different ways across the EU Member States, but most Europeans would agree that universal access to quality healthcare, at an affordable cost to both individuals and society at large, is a basic need. Moreover, this is one of the common values and principles in EU health systems.

Statistics on healthcare expenditure and financing may be used to evaluate how a country’s healthcare system responds to the challenge of universal access to quality healthcare, through measuring financial resources within the healthcare sector and the allocation of these resources between healthcare activities (for example, preventive and curative care) and groups of healthcare providers (for example, hospitals and ambulatory centres).

It should be noted that no data are available in this article for eight of the EU Member States — Denmark, Ireland, Italy, Latvia, Luxembourg, Malta, Slovenia and Slovakia — and for this reason EU-28 data are not provided as reference values.

This article forms part of an online publication on Health in the European Union.

Main statistical findings

Healthcare expenditure

Sweden, the Netherlands, Germany and France had the highest current healthcare expenditure relative to GDP among the EU Member States

The level of current healthcare expenditure in Germany was EUR 309 billion in 2013, equivalent to 10.9 % of gross domestic product (GDP). In France, current healthcare expenditure (EUR 231 billion) was also equivalent to 10.9 % of GDP, while the Netherlands (11.0 %) and Sweden (11.1 %) were the only EU Member States for which data are available to report higher ratios; note that current healthcare expenditure in Switzerland was equivalent to 11.2 % of GDP — see Table 1. By contrast, current healthcare expenditure accounted for less than 6.5 % of GDP in Poland, Lithuania and Estonia, with Romania recording the lowest ratio (5.2 %).

Relative to population size and in euro terms, current healthcare expenditure was highest among the EU Member States in Sweden, at EUR 5.0 thousand per inhabitant in 2013; three of the EFTA countries included in Table 1 — Norway, Switzerland and Liechtenstein — each reported higher expenditure per inhabitant.

The Netherlands was the only EU Member State (aside from Sweden) to record current healthcare expenditure above EUR 4.0 thousand per inhabitant, while France, Finland, Belgium, Germany and Austria, each recorded a ratio within the range of EUR 3.5 thousand–EUR 4.0 thousand per inhabitant. By contrast, seven EU Member States reported expenditure of less than EUR 1.0 thousand per inhabitant, with the lowest levels in Bulgaria (EUR 454 per inhabitant) and Romania (EUR 372 per inhabitant). As such, among the EU Member States, the ratio between the highest and lowest expenditure per inhabitant was 13.5:1.

These disparities were less after adjusting for price differences, by expressing expenditure in purchasing power standards (PPS): Germany and the Netherlands (both PPS 3.7 thousand per inhabitant) recorded the highest ratios of healthcare expenditure per capita, while Romania (PPS 767 per inhabitant) maintained its position at the lower end of the ranking. Taking account of price level differences, the ratio between the highest and lowest levels of healthcare expenditure per inhabitant narrowed to 4.9:1.

Healthcare expenditure by financing agent

Figure 1 provides a simple analysis of healthcare expenditure by financing agent, distinguishing public (government schemes, compulsory contributory health insurance schemes and compulsory medical saving accounts) and private (voluntary health insurance schemes, non-profit institutions serving households (NPISH) financing schemes, enterprise financing schemes, and household out-of-pocket payments) expenditure. With the exception of Cyprus, public expenditure exceeded private expenditure in all of the EU Member States for which data are available in 2013 and this was also true in the three EFTA countries shown in Figure 1.

The share of public expenditure in total current healthcare expenditure was in excess of 80.0 % in Croatia, Sweden, the Czech Republic, Germany and the Netherlands, as well as in Iceland and Norway.

Table 2 provides a more detailed analysis of healthcare expenditure by financing agent and Figure 2 shows the distribution among two of the main financing agents — government schemes; compulsory contributory health insurance schemes and compulsory medical saving accounts — and the rest.

An analysis of the financing of healthcare suggests that compulsory contributory health insurance schemes and compulsory medical saving accounts (which are generally part of the social security system) were a fairly common means for funding healthcare within the EU Member States. For example, these accounted for more than three quarters of overall spending on healthcare in Germany (77.5 %), the Czech Republic (77.9 %), Croatia (78.2 %) and the Netherlands (80.4 %) in 2013, but less than 5.0 % in Spain, Portugal, Cyprus, the United Kingdom and Sweden. By contrast, the United Kingdom and Sweden reported that government schemes accounted for more than three quarters (79.4 % and 83.4 % respectively) of their total current expenditure on healthcare, while shares of 60–70 % were registered in Finland, Portugal and Spain.

The major source of private funding was household out-of-pocket payments, which peaked in terms of their share of current healthcare expenditure in Cyprus (47.3 %) and Bulgaria (47.2 %), falling to a single-digit share in France (7.2 %) and the Netherlands (5.3 %). Voluntary health insurance schemes generally represented a small share of healthcare financing among the EU Member States; their relative share peaked, among those Member States for which data are available, at 13.8 % in France, which was almost twice as high as the next highest share recorded in Croatia (7.7 %).

Healthcare expenditure by function

Curative care and rehabilitative care services accounted for more than half of current healthcare expenditure in the majority of EU Member States

The functional patterns of healthcare expenditure presented in Table 3 and Figure 3 show that in 2013 curative care and rehabilitative care services incurred more than 50.0 % of current healthcare expenditure in the vast majority of EU Member States for which data are available, the exceptions being Belgium, Bulgaria and Croatia where the share was only just under half; curative care and rehabilitative care services in Norway also incurred just less than half (49.2 %) of current healthcare expenditure.

By contrast, at the upper end of the range, close to two thirds (66.1 %) of total healthcare expenditure was incurred by curative care and rehabilitative care services in Portugal; Cyprus, the Czech Republic and Poland also recorded shares that were in excess of 60.0 %.

Medical goods accounted for around one quarter of total current healthcare expenditure

Medical goods were generally the second largest function, although with a significant degree of variation: the lowest shares — less than 15.0 % — were recorded for the United Kingdom, Finland, Sweden and the Netherlands, while the highest shares — rising to more than 30.0 % of healthcare expenditure — were recorded for Greece, Lithuania, Hungary, Croatia, Romania and Bulgaria.

Services related to long-term (health) care accounted for less than 10.0 % of current healthcare expenditure in more than half of the EU Member States for which data are available in 2013, but for more than one fifth of the total in Belgium and more than one quarter of the total in the Netherlands and Sweden, peaking in the latter at 26.3 %; an even higher share (28.8 %) was recorded in Norway. It should be noted that limitations within the data compilation exercise make it difficult to separate the medical and social components of expenditure for long-term care, leading to an inevitable impact on cross-country comparisons. An analysis of expenditure for long-term care, which includes both its health/medical and social care components, is provided later in this article. In addition, the relatively low shares reported for some of the EU Member States could be due to the main burden of long-term (health) care residing with family members, with no payment being made for providing these services.

The proportion of current healthcare expenditure incurred by ancillary services (such as laboratory testing or the transportation of patients) varied considerably among EU Member States, ranging from 1.8 % in the Netherlands and the United Kingdom to 8.9 % in Croatia, with Estonia (10.3 %) and Cyprus (11.0 %) above this range.

Expenditure related to preventive care exhibited less variation between EU Member States. Its highest share of current healthcare expenditure in 2013 was recorded in the United Kingdom (4.2 %), while shares were 3.0 % or a little higher in Estonia, Sweden, Germany, the Netherlands and Finland. By contrast, the share of preventive care in current healthcare expenditure was less than 1.0 % in the Czech Republic and Cyprus.

Expenditure on governance and health system and financing administration ranged from a high of 6.1 % in France and 5.1 % in Germany down to 1.5 % in Bulgaria and Finland, and 1.4 % in Sweden. The share of current healthcare expenditure dedicated to governance and health system and financing administration was particularly low in Norway, at 0.6 %.

Healthcare expenditure by provider

An analysis of current healthcare expenditure by provider is shown in Table 4 and Figure 4. It should be borne in mind that healthcare providers classified under the same group do not necessarily perform the same set of activities. For example, hospitals may offer day care, out-patient, ancillary or other types of service, in addition to in-patient services.

In most EU Member States hospitals were the main provider of healthcare in expenditure terms

Hospitals generally accounted for the highest proportion of current healthcare expenditure in 2013, ranging from 29.5 % of the total in Germany to 47.6 % in Estonia. Germany and Bulgaria were the only EU Member States, among those for which data are available, to report that hospitals did not have the highest share of healthcare expenditure, as ambulatory health care providers accounted for 31.1 % of total healthcare expenditure in Germany, while retailers and other providers of medical goods accounted for 42.4 % of total healthcare expenditure in Bulgaria.

The second most important category was generally that of ambulatory health care providers, their share of healthcare expenditure ranging from 10.4 % in Romania to more than 30.0 % in Germany and Belgium; ambulatory health care providers in Liechtenstein accounted for 31.7 % of total healthcare expenditure.

The share of healthcare expenditure that was accounted for by retailers and other providers of medical goods was also generally quite high. It varied by a factor of four, with the lowest shares — below 15.0 % — being recorded in Cyprus, Belgium, the Netherlands and Sweden (which registered the lowest share, at 10.9 %). Most of the EU Member States reported that retailers and other providers of medical goods accounted for between 15.0 % and 23.8 % of current healthcare expenditure in 2013, with somewhat higher shares (between 30.9 % and 35.5 %) in Greece, Lithuania, Hungary, Croatia and Romania, rising to 42.4 % in Bulgaria.

Long-term care expenditure

Among the EU Member States, the share of long-term care services in current healthcare expenditure peaked at 42.0 % in Finland

The share of long-term care services (including both the health and social components of long-term care) in current healthcare expenditure varied enormously among the EU Member States as can be seen in Figure 5. In four EU Member States — Estonia, Cyprus, Greece and Bulgaria — long-term care accounted for 5.0 % or less of current healthcare expenditure. The next lowest share was recorded in Portugal (9.9 %), while there were six EU Member States that recorded a share within the range of 10.2 %–18.4 %. At the other end of the scale, long-term care as a share of current healthcare expenditure rose to almost one quarter (23.9 %) in Belgium, almost one third (31.5 %) in Sweden and to more than two fifths (42.0 %) in Finland. Among the EFTA countries shown in Figure 5, shares over 30.0 % were also reported for Switzerland and Norway.

The high shares of long-term care in total current healthcare expenditure in Finland and Sweden are reflected in the data presented in Table 5: long-term care expenditure in Finland was equivalent to 4.0 % of GDP in 2013 and in Sweden it was equivalent to 3.5 %. Belgium (2.5 %) was the only other EU Member State among those for which data are available to record a ratio above 2.0 %, while France, the United Kingdom, Germany and Austria recorded ratios between 1.5 % and 1.9 %. The remaining seven Member States for which data are available reported that long-term care expenditure was equivalent to less than 1.0 % of GDP, with this share falling as low as 0.01 % in Bulgaria.

Long-term care expenditure in 2013 exceeded EUR 1.0 thousand per inhabitant in Finland and Sweden

Relative to population size and in euro terms, long-term care expenditure was highest in 2013 among the EU Member States in Sweden (EUR 1.6 thousand per inhabitant) and Finland (EUR 1.5 thousand per inhabitant); among the non-member countries included in Table 5, both Norway and Switzerland reported higher ratios, while Liechtenstein also recorded long-term care expenditure above EUR 1.0 thousand per inhabitant. A total of four EU Member States reported less than EUR 100 of long-term care expenditure per inhabitant in 2013, with the lowest average level of expenditure in Bulgaria (EUR 0.5 per inhabitant).

Data sources and availability

No data are available in this article for eight of the EU Member States: Denmark, Ireland, Italy, Latvia, Luxembourg, Malta, Slovenia and Slovakia. In addition, there are no data available for some other Member States in particular tables or figures. For this reason, EU-28 data are not provided in this article. When available, data are also presented for the four EFTA countries.

Note on tables: the symbol ‘:’ indicates that data are not available.

Key concepts

Total healthcare expenditure quantifies the economic resources of both the public and private sectors dedicated to health functions, excluding capital investment. Healthcare expenditure concerns itself primarily with healthcare goods and services that are consumed by resident units, irrespective of where that consumption takes place (it may be in the rest of the world) or who is paying for it. As such, exports of healthcare goods and services (to non-resident units) are excluded, whereas imports of healthcare goods and services for final use are included.

Long-term healthcare consists of a range of medical and personal care services that are consumed with the primary goal of alleviating pain and suffering and reducing or managing the deterioration in health status in patients with a degree of long-term dependency. The aim of long-term social care is to provide services and support, by formal and informal care givers, to individuals who, for reasons of disability, illness or other dependency, need help to live as normal a life as possible. Social care covers a wide range of services, including professional advice and support, accommodation, various types of assistance in carrying out daily tasks, home visits, home help services, provision of meals, special equipment, house adaptation for disabled persons, as well as assessment and care management services. There may be a mixed economy of health and social care provision and this mix of services can make it difficult to separate expenditure between health and social components. For the purpose of this article, the aggregate covering long-term care (as shown in Figure 5 and Table 5) is composed of both health and social components, as this is usually considered as being of greater policy relevance.

System of health accounts

Eurostat, the Organisation for Economic Cooperation and Development (OECD) and the World Health Organisation (WHO) established a common framework for a joint healthcare data collection exercise. The data collected relates to healthcare expenditure following the methodology of the system of health accounts (SHA).

The SHA shares the goals of the system of national accounts (SNA): to constitute an integrated system of comprehensive, internally consistent, and internationally comparable accounts, which should as far as possible be compatible with other aggregated economic and social statistical systems. Health accounts provide a description of the financial flows related to the consumption of healthcare goods and services from an expenditure perspective. Health accounts are used in two main ways: internationally, where the emphasis is on a selection of internationally comparable expenditure data; nationally, with more detailed analyses of healthcare spending and a greater emphasis on comparisons over time.

In 2011, and as a result of four years of extensive and wide-reaching consultation, Eurostat, the OECD and the WHO released an updated manual for the collection of health accounts, ‘A system of health accounts, 2011 edition’. The core set of SHA tables addresses three basic questions: i) what kinds of healthcare goods and services are consumed; ii) which healthcare providers deliver them, and; iii) which financing schemes are used to deliver them?

Healthcare expenditure is recorded in relation to the international classification for health accounts (ICHA), defining:

healthcare expenditure by financing agent (ICHA-HF) — which provides an analysis of public and private units that directly pay providers for the provision of healthcare goods and services — such as government schemes, compulsory health insurance, enterprise schemes, or out-of-pocket payments;
healthcare expenditure by function (ICHA-HC) — which details the split in healthcare expenditure following the purpose of healthcare activities — such as, curative care, rehabilitative care, long-term care, or preventive care;
healthcare expenditure by provider (ICHA-HP) — which classifies units contributing to the provision of healthcare goods and services — such as hospitals, residential facilities, ambulatory health care services, ancillary services or retailers of medical goods.

Healthcare expenditure — methodology

Commission Regulation (EU) 2015/359 of 4 March 2015 implementing Regulation (EC) No 1338/2008 as regards statistics on healthcare expenditure and financing paves the way for healthcare expenditure data collection according to SHA 2011 methodology. The Regulation applies to data from reference year 2014 onwards; these results should be available around the end of 2016.

The data shown in this article are systematically presented for reference year 2013. EU Member States submitted their data for reference year 2013 to Eurostat on the basis of a gentlemen’s agreement, in advance of the collection of data for reference year 2014 based on the 2015 legislation. The information presented is founded on common definitions and specifications: since the update of this article in autumn 2016 the methodological basis is SHA 2011.

SHA 2011 introduces a number of changes and improvements compared with SHA 1.0. It reinforces the tri-axial relationship that is at the root of the SHA and its description of healthcare and long-term care expenditure. SHA 2011 offers more complete coverage within the functional classification in areas such as prevention and long-term care; a more concise picture of the universe of healthcare providers; and a more precise approach for tracking financing in the healthcare sector.

Statistics on healthcare expenditure are documented in this background article which provides more information on the scope of the data, the legal framework, the methodology employed, as well as related concepts and definitions.

Context

Health systems across the globe are developing in response to a multitude of factors, including: new medical technology and improvements in knowledge; new health services and greater access to them; changes in health policies to address specific diseases and demographic developments; new organisational structures and more complex financing mechanisms. However, access to healthcare and greater patient choice is increasingly being considered against a background of financial sustainability. Many of the challenges facing governments across the EU were outlined in the European Commission’s White paper titled ‘Together for health: a strategic approach for the EU 2008–2013’ (COM(2007) 630 final). It builds on the Council Conclusions on ‘Common values and principles in European Union Health Systems’ (2006/C 146/01).

In February 2013, the European Commission adopted a Communication titled ‘Towards social investment for growth and cohesion’ (COM(2013) 83 final). The main axes of the Communication included: ensuring that social protection systems respond to people’s needs at critical moments throughout their lives; simplified and better targeted social policies, to provide adequate and sustainable social protection systems; and upgrading active inclusion strategies in the EU Member States.

In March 2014, the third multi-annual programme of EU action in the field of health for the period 2014–2020 was adopted (Regulation (EU) No 282/2014) under the title ‘Health for Growth’. This new programme emphasises the link between health and economic prosperity, as the health of individuals directly influences economic outcomes such as productivity, labour supply and human capital. More information is provided in the introductory article for health statistics.

In April 2014, the European Commission adopted a Communication ‘On effective, accessible and resilient health systems’ (COM(2014) 215 final). Capitalising on experience and work carried out over recent years, and with a view to further developing approaches for the EU, this Communication focuses on actions to strengthen the effectiveness of health systems, increase the accessibility of healthcare and improve the resilience of health systems.

On the basis of Eurostat’s 2013 population projections (EUROPOP2013), long-run economic and budgetary projections aimed at assessing the impact of ageing population were published in 2015. This constituted the fifth release of such long-run projections since 2001. On the basis of underlying demographic and macro-economic assumptions and projections, age-related expenditures covering pensions, healthcare, long-term care, education and unemployment benefits were projected and analysed. The projections feed into a variety of policy debates in the EU, including the overarching Europe 2020 strategy. In particular, they are used in the context of the European semester so as to identify policy challenges, in the annual assessment of the sustainability of public finances carried out as part of the stability and growth pact.

The European Commission’s Directorate-General for Health and Food Safety has constituted a list of 88 European core health indicators (ECHIs). Among these, it recommends specifically following developments for:

Further Eurostat information

Database

Health care (hlth_care), see:

Healthcare expenditure (hlth_sha)

Health care expenditure (SHA 2011) (from 2003 onwards) (hlth_sha11)

External links