Boletin Nº 10 COMSOR by Colegio de Medicos de Soria

Revista Quincenal

Ilustre Colegio Oficial de

Médicos de Soria www.comsor.es 1ª Quincena de diciembre de 2012

Edición Nº 10 · 2012

Avda. Mariano Vicén, 31, 1º piso 42003 SORIA Teléf. 975 22 29 92 y 975 22 29 58 FAX 975 21 17 21 http://www.comsor.es administracion1@comsor.es administracion2@comsor.es

Indice de Contenidos Edición Nº 10 1ª Quincena de diciembre de 2012

Firmas en defensa del Hospital Público de Soria . . . . . 3 Continúan las movilizaciones en Madrid . . . . . . . . . 3 Modelo de Autonomía de Gestión en Atención Primaria en Madrid. . . . . . . . . . . . . . . . . . . . . . . . . . . 3 El Foro de la Profesión Médica exige soluciones a la situación de Madrid y se suma a la manifestación de febrero. . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Profesión médica y reforma sanitaria . . . . . . . . . . . 3 La OMC solicita a Echániz que rectifique . . . . . . . . . 4 Panorama de la Salud: Europa 2012. . . . . . . . . . . . 4 Boletín Europa al día Nº 380 PANORAMA DE LA SALUD: EUROPA 2012. . . . . . . . . . . . . . . . . . . . . . . 4 Conclusiones VIH 2012 . . . . . . . . . . . . . . . . . . 4 PAIME: atención al médico enfermo. . . . . . . . . . . . 5 Propuesta de Cursos de Inglés para Médicos SpanDoc. . 5 Prueba ECOE. . . . . . . . . . . . . . . . . . . . . . . 5 EL COLEGIO INVITA A TODOS SUS COLEGIADOS A PARTICIPAR CON SUS APORTACIONES (CIENTIFICAS, PROFESIONALES, OPINIONES, INFORMACIONES, NOTICIAS, ETC.) EN NUESTRA REVISTA ELECTRÓNICA QUINCENAL.. . . . . . . . . . . . . . . . . . . . . . . . 5 Ofertas de Empleo . . . . . . . . . . . . . . . . . . . . . 5 Médico especializado en Urología pediátrica.. . . . 5 Ofertas de trabajo para MEDICO OFTALMOLOGO en FRANCIA.. . . . . . . . . . . . . . . . . . . . . . 7 El Hospital Universitario Río Hortega de Valladolid quiere proceder a la contratación de Médicos Especialistas en Radiodiagnóstico con experiencia en patología mamaria.. . . . . . . . . . . . . . . . . . 9 Nuevas Ofertas de Empleo para especialistas en Reino Unido. . . . . . . . . . . . . . . . . . . . . 10 Oferta de trabajo en Londres . . . . . . . . . . . . . . . . . . . . 14 Oferta de trabajo en Castellón. . . . . . . . . . . . . . . . . . . 14 El Hospital Reina Sofía de Tudela (Navarra) necesita un facultativo especialista en Ginecología y otro facultativo especialista en Traumatología. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 OFERTA DE TRABAJO MÉDICO/A de ADECCO MEDICAL &

SCIENCE SALAMANCA,. . . . . . . . . . . . . . . . . 14 Centro de reproducción asistida ubicado en Sevilla, oferta puesto de ginecólogo/a especialista. . . . . . . . . . . . . . . . . . . . . 15 NUEVAS OPORTUNIDADES PARA MEDICOS EN EL REINO UNIDO . 15 Ofertas de empleo de Hertfordshire Partnership NHS Foundation Trust. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Grupo Clave Servicios Empresariales selecciona Director Médico del Trabajo para importante empresa de ámbito nacional con sede en Lugo.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Fundación de Hemoterapia y Hemodonación de Castilla y León BUSCA LICENCIADOS EN MEDICINA PARA TRABAJAR EN SEGOVIA Y PROVINCIA Y EN CASTILLA Y LEON. . . . . . . . . 16

Anexos. . . . . . . . . . . . . . . . . . . . . . . . . . 24

COMSOR.ES

Boletín Informativo

Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012

Firmas en defensa del Hospital Público de Soria

La Plataforma en Defensa del Hospital Santa Bárbara de Soria, encabezada por el Colegio Oficial de Médicos de Soria, ha registrado más de 3.000 firmas en la Consejería de Sanidad de la Junta de Castilla y León para exigir a la Administración Regional que ejecute la segunda fase de las obras del Hospital Público de Soria. Finalmente los presupuestos regionales no incluyen esta infraestructura, aunque dedican dos millones de euros a diferentes actuaciones. Desde el COMSOR se pide la ejecución del plan completo tal y como estaba previsto.

Continúan las movilizaciones en Madrid

El conflicto entre el sector sanitario y la Comunidad de Madrid está, de momento, lejos de solucionarse. Los profesionales continúan con diferentes movilizaciones, incluida la huelga, y la mitad de los equipos directivos de los centros de salud han firmado una carta anunciando su dimisión si el Gobierno Regional continúa con sus planes de privatización. http://www.elmundo.es/elmundosalud/2012/12/20/noticias/1356024882.htm http://ccaa.elpais.com/ccaa/2012/12/20/madrid/1356012619_886592.html http://ccaa.elpais.com/ccaa/2012/12/20/madrid/1356008417_569102.html

Modelo de Autonomía de Gestión en Atención Primaria en Madrid

Desde los diferentes colectivos vinculados con el Sistema Nacional de Salud, incluido el Colegio de Médicos de Madrid, se ha elaborado un estudio que analiza la situación de la sanidad madrileña y las consecuencias de las medidas anunciadas por la Administración Regional. La Ley de Presupuestos de la Comuniad de Madrid para 2013 incluye el “Plan de Garantía de sostenibilidad del Sistema Sanitario Público” que, entre otras medidas, contempla sacar a concurso la gestión de 27 centros de salud. Esta medida supone, en la práctica, la salida de los trabajadores: médicos de familia, pediatras, enfermeras, matronas, administrativos y personal de apoyo. Adjuntamos informe completo en la sección anexos.

El Foro de la Profesión Médica exige soluciones a la situación de Madrid y se suma a la manifestación de febrero

El Foro de la Profesión Médica, en su reunión del 13 de diciembre, decidió exigir una solución inmediata a la situación actual de la sanidad en la Comunidad de Madrid. Desde el Foro califican la respuesta de los profesionales a las medidas adoptadas por el Gobierno de la Comunidad como “coherente y adecuada”. Además, el colectivo reitera su apoyo a la manifestación convocada el próximo 23 de febrero en Madrid con el objeto de; por un lado, defender a ultranza el SNS y, por otro, mostrar un rechazo unánime a las medidas indiscriminadas que afecten a la calidad de la asistencia y a la buena praxis tanto a nivel del Estado como de las Comunidades Autónomas. Adjuntamos comunicado en la sección anexos

Profesión médica y reforma sanitaria

La OMC ha presentado a Nuñez Feijoo, presidente de la Xunta de Galicia, un documento con diferentes propuestas para llevar a cabo la reforma sanitaria que garantice la sostenibilidad del sistema. Acuerdo político, financiación estable, buen gobierno en el Sistema Nacional de Salud, buena gestión en centros y servicios y un contrato social renovado con los sanitarios, son los cinco puntos clave que incluye el documento. El texto de la OMC considera que “la respuesta sostenible y eficiente a la crisis financiera en la sanidad, exige cambios estructurales y de estrategias” pero expone que “los recortes lineales bloquean estos cambios e imponen reducciones que no sólo afectan a lo prescindible si lo hubiera, sino que también a lo imprescindible para mantener la calidad de los servicios sanitarios”. Adjuntamos más información en la sección anexos. PAGINA

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Boletín Informativo

Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012

La OMC solicita a Echániz que rectifique

El secretario general de la OMC, Serafin Romero, ha solicitado al Consejero de Sanidad de Castilla la Mancha, José Ignacio Echániz, una rectificación inmediata de sus declaraciones en relación a las “peonadas” en las que pone de manifiesto graves acusaciones contra los profesionales médicos a los que acusa de “realizar intervenciones innecesarias” a cambios de emolumentos económicos. Adjuntamos comunicado de la OMC en la sección anexos

Panorama de la Salud: Europa 2012

La Comisión Europea y la OCDE han publicado conjuntamente un informe que recoge los indicadores clave sobre los factores determinantes de la salud, los recursos y actividades de la asistencia sanitaria, la calidad de la atención sanitaria y el gasto y financiación de los 35 países europeos. En general la situación ha mejorado notablemente, aunque persisten las grandes diferencias. http://www.cmourense.org/Blog/contenido/950/PANORAMA_DE_LA_SALUD_EUROPA_2012

Boletín Europa al día Nº 380 PANORAMA DE LA SALUD: EUROPA 2012

La Comisión Europea y la OCDE han publicado conjuntamente un informe que, bajo el título Panorama de la salud: Europa 2012, recoge los indicadores clave sobre los factores determinantes de la salud, los recursos y actividades de la asistencia sanitaria, la calidad de la atención sanitaria y el gasto y la financiación de la salud en 35 países europeos, que son, los 27 Estados miembros de la UE, 5 países candidatos y 3 países de la AELC/EFTA. Entre las principales conclusiones del informe, podemos señalar las siguientes: • En general, la situación sanitaria ha mejorado considerablemente aunque siguen existiendo grandes diferencias. • El número de médicos y de enfermeros per cápita es más alto que nunca en la mayoría de los países, pero preocupa la escasez actual o futura de personal. • La esperanza de vida al nacer en los países de la UE aumentó en más de seis años entre 1980 y 2010. • La prevalencia de enfermedades crónicas como la diabetes, el asma y la demencia es cada vez más elevada. • La mayor parte de los países europeos ha reducido el consumo de tabaco mediante campañas de sensibilización de la opinión pública, la prohibición de la publicidad y mayores impuestos. • El aumento del gasto sanitario per cápita se ralentizó o incluso se detuvo en términos reales en 2010 en casi todos los países europeos, lo que invirtió una tendencia de incremento constante. En el presente Boletín “Europa al día” ampliamos esta información e incluimos el texto íntegro del informe del que sólo existe versión inglesa.

Conclusiones VIH 2012

Las tasas de nuevos diagnósticos en España son similares a las de otros países en Europa Occidental, aunque superiores a la media de la Unión Europea, según se desprende del último estudio realizado. Promover el diagnóstico precoz debe ser un factor clave para controlar la epidemia en Europa, teniendo en cuenta que el retraso en el diagnóstico sigue siendo una asignatura pendiente y sólo ha descendido entre los HSH. Adjuntamos informe en la sección anexos.

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Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012

PAIME: atención al médico enfermo

El Programa de Atención Integral al médico Enfermo (PAIME) es un programa para facilitar a los médicos el acceso a una tención sanitaria de calidad y especializada en caso de enfermedades relacionadas con trastornos psíquicos o conductas adictivas que puedan interferir en su práctica profesional. Teléfono de información: 628793793 Adjuntamos más información en sección anexos.

Propuesta de Cursos de Inglés para Médicos SpanDoc Podéis ampliar la información en el enlace siguiente: http://www.spandoc.com/colegiosmedicos.html

Prueba ECOE Os informamos de que se ha aprobado el borrador de proyecto sobre el acceso excepcional al título de Médico Especialista en Medicina Familiar y Comunitaria (prueba ECOE). La fecha de solicitud de la ECOE pasa del 31/1/2013 al 31/3/2013.

EL COLEGIO INVITA A TODOS SUS COLEGIADOS A PARTICIPAR CON SUS APORTACIONES (CIENTIFICAS, PROFESIONALES, OPINIONES, INFORMACIONES, NOTICIAS, ETC.) EN NUESTRA REVISTA ELECTRÓNICA QUINCENAL. ¡ ANIMO ! ES VUESTRA

Ofertas de Empleo Médico especializado en Urología pediátrica. Responsable de dirigir y supervisar la prestación de atención de alta calidad basada en la eficacia, diagnosticar y dirigir una eficiente gestión, en el tratamiento de todos los pacientes. Del médico tratante se espera que sea un ejemplo de excelencia clínica dentro de su especialidad así como proporcionar liderazgo y capacitación para el personal médico junior. Se espera que demuestren un gran interés y participación activa en la investigación. Funciones principales: Soportes, implementos y sigue todas las iniciativas Cliente, departamentos y divisiones políticas y procedimientos.

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Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012

Ayude a dirigir, ejecutar, y participar en la gestión del desempeño de la organización del sistema, incluyendo la revisión inter pares y el proceso de revisión de la productividad y la utilización. Revisar las actividades clínicas del personal médico junior y asumir la responsabilidad del cuidado que proporcionan. Diagnosticar y tratar a pacientes de acuerdo con las normas establecidas del puesto. Fomentar una cultura de mejora, aprendizaje y desarrollo continuo a través del departamento de urología. Cumplir con todas las políticas establecidas en materia de admisión de clientes, consultas, diario del paciente, atención, procedimientos quirúrgicos, protocolos de descarga, consulta externa y seguimiento de prácticas. Prácticas adecuadas para la utilización de los recursos del cliente. Realizar tareas clínicas y garantizar la continuidad de la atención. Participar en actividades de desarrollo de la investigación con un enfoque profesional y aplicarse con conformidad. Responsabilidades específicas del trabajo: Dirigir, evaluar y reconsiderar los pacientes hospitalizados de forma regular, con el mejor servicio posible. Regularmente revisar los resultados de todas las investigaciones y modificar el tratamiento según sea necesario. Servir de enlace con otras especialidades médicas y servicios de apoyo para el ingreso adicional que sea necesario. Participar activamente en las reuniones multidisciplinarias para ayudar a planificar la atención eficaz, segura y holística para los pacientes individuales. Aceptar pacientes clínicamente proporcionados desde el Servicio de Urgencias, Atención Primaria, u otros departamentos, clínicas de especialidades. Comunicar la información clínica de los pacientes a familiares del paciente o amigos (con consentimiento del paciente) de una manera oportuna. Mantener la confidencialidad con respecto a cualquier intercambio de información recibida de acuerdo con la política del cliente. Asumir el papel de embajador de la marca para el establecimiento y la promoción de una filosofía del cliente en el trato con las partes interesadas. Organizar y llevar a cabo un programa de mejora de calidad para la división, los monitores y Los informes sobre las iniciativas de calidad al Jefe de División. Participar en programas para enseñar a los estudiantes, la formación de médicos y en la práctica clínica de exámenes. Facilitar el suministro de capacitación pertinente indispensable para el personal clínico en la especialidad. Mostrando compromiso con la Educación Médica Continua (CME) Requisitos:

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Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012 El cumplimiento satisfactorio de un Consejo de Acreditación de Educación Médica para Graduados (ACGME) programa de residencia en los Estados Unidos y la certificación por una de las especialidades médicas, juntas de la Junta Americana de Especialidades Médicas (ABMS) El cumplimiento satisfactorio de un programa de residencia acreditado por el Colegio Real de Médicos y Cirujanos de Canadá, y la Certificación de Especialistas por el Colegio Real de Médicos y Cirujanos de Canadá. El cumplimiento satisfactorio de un programa de entrenamiento de residencia acreditado por una autoridad competente de un Estado miembro de la Comunidad Europea, o certificación de especialista de acuerdo con el Consejo Directiva. Se necesita un nivel de Inglés MUY alto. Más información: En Doha, la capital de Qatar, nuestro cliente es una instalación del estado que se centrará principalmente en la mujer y la salud de los niños. Además de proporcionar servicios de clase mundial de salud, el centro también será un ambiente de aprendizaje para los estudiantes de medicina y residentes, que abarca cooperativamente la investigación nacional e internacional. La calidad de primera clase de cliente se refleja en el diseño innovador del centro y en el uso de las más modernas tecnologías de última generación. Beneficios: -Ingresos libres de impuestos -Alojamientos completamente amueblado. -Billetes de vuelos anuales -Cobertura médica completa -Vacaciones anuales pagadas -Las ofertas están supeditadas a recibir una visa de trabajo, una vez que la visa es otorgada, el proceso para llegar hasta el país de destino y puesto de trabajo. -Cuando se hace una oferta, el candidato seleccionado deberá suministrar la información documentos y referencias necesarios. Este proceso puede tomar desde una semana a un mes.

equipo de on-boarding le guiará a través del

Laboratorio privado en el norte de Alemania Para el sobresaliente laboratorio de uno de nuestros clientes, buscamos para lo antes posible, un Fachärztin/Facharzt für Laboratoriumsmedizin El laboratorio está acreditado tanto para medicina como para forense y cuenta con los más modernos aparatos de análisis. Las tareas a realizar entre otros serán: La responsabilidad del análisis en el laboratorio La validación medica Aconsejar en el marco del diagnostico del laboratorio Perfil: Licenciatura en medicina Especialidad relacionada con laboratorios Alemán B2 mínimo Inglés alto ENVIAR CV en inglés y datos de contacto a c.pinilla@binternational.es con asunto “Urología pediatrica” o “Especialista en Laboratorio”.

Ofertas de trabajo para MEDICO OFTALMOLOGO en FRANCIA.

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Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012

Anglet, 5 de diciembre de 2012 Estimados Sres.: Somos Laborare Conseil, especializada en procesos de selección de personal sanitario para trabajar en Francia y en Holanda, en hospitales, consultas o clínicas, según la oferta que sea difundida y el origen de la misma (a veces contrato privado y a veces en el marco de concursos públicos ganados por nuestra empresa para contratar personal para hospitales). Actualmente realizamos nuevos procesos de selección de 1 MEDICO OFTALMOLOGO para INSTALARSE EN FRANCIA COMO ASALARIADO CON CONTRATO LABORAL FIJO. Además de esta oferta actualmente abierta, les informamos de que regularmente contratamos MEDICOS DE CUALQUIER ESPECIALIDAD para trabajar en Francia y en los Países Bajos (Holanda), por lo que les estaríamos muy agradecidos si realizaran la difusión general de nuestras ofertas que adjunto remitimos para que las personas interesadas pudieran ir ganando tiempo y enviar su candidatura, pues determinados puestos de trabajo se cubren con candidaturas espontáneas inmediatamente. Les estaríamos muy agradecidos si validaran esta información y procedieran a su difusión a través de su tablón de anuncios, o por el medio que ustedes consideren oportuno. Si necesitaran un soporte informático de estos documentos, o cualquier información complementaria, no duden en solicitárnoslo en el e-mail y.brugos@laborare-conseil.com Les agradeceríamos también si indicaran a los interesados que las candidaturas se deben enviar al mail medecin@laborare-conseil.com, lo que facilitará su posterior tratamiento. Para cualquier aclaración o información complementaria que puedan desear, no duden en enviar un mail a y.brugos@laborare-conseil.com Sin otro más particular, reciban un cordial saludo: Sra. Yael Brugos Miranda y.brugos@laborare-conseil.com / www.laborare-conseil.com LABORARE CONSEIL es una empresa certificada OPQCM en los campos de la selección de personal, de los recursos humanos y generalista. ISQ-OPQCM es el único organismo profesional francés de certificación de empresas de servicios intelectuales reconocido por el Ministerio de Economía, de Industria y de Empleo.

Laborare Conseil, especializada en la selección de personal sanitario europeo, selecciona, para un importante grupo de salud francés, a tres horas en coche de Barcelona y tres horas y media de Irún, y una hora del aeropuerto internacional de Toulouse 1 MEDICOS OFTALMOLOGO Motivado para INSTALARSE EN FRANCIA Y TRABAJAR EN CONSULTAS COMO ASALARIADO, a lo largo del año 2013 Se ofrece: -Contrato fijo en régimen general de seguridad social. -Salario mínimo garantizado durante los 3 primeros meses: 4000 € brutos al mes, pudiéndose estimar una media de salario bruto mensual de entre 5.800 euros para principiantes y 14.500 para profesionales con experiencia confirmada y técnica avanzada. -Horarios fijos y adaptables. -Son organizados y coste a cargo de la empresa: material, secretaria, gestión administrativa... -Formación sobre el idioma técnico, y colaboración posible en la enseñanza del francés, si ello es necesario y así se acuerda con el candidato. FRANCES: no se exige por tanto hablarlo en el momento de la entrevista y selección, aunque el médico interesado deberá estudiarlo por su cuenta y a su propio coste antes de empezar a trabajar. Además, la mutualidad podrá cofinanciar el aprendizaje de la lengua francesa del candidato, parcialmente, y según nivel inicial del candidato.

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Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012 -Alojamiento gratuito durante 3 meses. -Interesantes perspectivas de evolución profesional. Interesados contactar con Yael BRUGOS MIRANDA enviando CURRICULUM VITAE a medecin@laborare-conseil.com LABORARE CONSEIL es una empresa certificada OPQCM en los campos de la selección de personal, de los recursos humanos y generalista. ISQ-OPQCM es el único organismo profesional francés de certificación de empresas de servicios intelectuales reconocido por el Ministerio de Economía, de Industria y de Empleo. Laborare Conseil, especializada en la selección de personal sanitario europeo, selecciona, para VARIOS HOSPITALES CONSULTAS Y CLINICAS sitas en varias ciudades francesas, MEDICOS DE TODO TIPO DE ESPECIALIDADES: RADIOLOGOS, ANESTESISTAS REANIMADORES, DE URGENCIAS, ANATOMIA PATOLOGICA, MEDICINA INTERNA, DE FAMILIA, PEDIATRIA, GERIATRIA, CARDIOLOGIA… TODOS LOS PERFILES Y ESPECIALIDADES SERAN ESTUDIADOS Motivados para TRABAJAR EN FRANCIA O EN LOS PAISES BAJOS (HOLANDA) a lo largo del año 2013 Se ofrece: -Contrato asalariado del sector público, del sector privado o de colaboración siendo autónomo, punto variable según la oferta. -Retribución/facturación variable según la oferta, y según el número de pacientes que tratar (se explicarán condiciones de oferta concreta a candidatos concretos). -Enseñanza del lenguaje técnico. -Francés general: poseer conocimientos de la lengua francesa previamente sería un plus, pero no es condición indispensable inicial. El candidato deberá comprometerse a estudiar el francés previamente si aún no posee un nivel adecuado. -Alojamiento en general no gratuito (punto variable según la oferta) aunque ayudamos a encontrar el mismo. -Interesantes perspectivas de evolución profesional. -Puestos disponibles a lo largo de todo el año 2012 o del primer trimestre de 2013. -Apoyo administrativo, logístico y formativo, y de material, para facilitar la instalación del nuevo dentista. Interesados contactar con Yael BRUGOS MIRANDA indicando referencia INSTALACION EN CONSULTA enviando CURRICULUM VITAE a medecin@laborare-conseil.com LABORARE CONSEIL es una empresa certificada OPQCM en los campos de la selección de personal, de los recursos humanos y generalista. ISQ-OPQCM es el único organismo profesional francés de certificación de empresas de servicios intelectuales reconocido por el Ministerio de Economía, de Industria y de Empleo.

El Hospital Universitario Río Hortega de Valladolid quiere proceder a la contratación de Médicos Especialistas en Radiodiagnóstico con experiencia en patología mamaria. Las personas interesadas pueden enviar su Currículo Vital a la Dirección Medica del HURH al e-mail: dirmed. hurh@saludcastillayleon.es PAGINA

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Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012 Nuevas Ofertas de Empleo para especialistas en Reino Unido ANESTESISTA - UK Nº Vacantes: 1 País: Wales, UK Salario: £36,807 - £68,638 Requerimientos mínimos: • Anestesista con 4 años de experiencia, y al menos 2 como anestesista • Se valora experiencia previa en NHS • Inglés C1 o C2 CARDIÓLOGO Nº Vacantes: 1 País: Wales, UK Salario: £36,807 - £68,638 Requerimientos mínimos: • Cardiólogo con 4 años de experiencia, y al menos 2 como cardiólogo • Inglés C1 o C2 • Experiencia: o Experiencia trabajando de forma efectiva como parte de equipo multidisciplinario o Compromiso con trabajo en equipo y disciplinario o Se valora experiencia como parte de equipo de dirección o Coordinación con otras agencias u organismos o Educación y entrenamiento de personal médico graduado y no graduado o Se valora iniciación, progreso y cumplimentación de auditorías o Se valora capacidad experiencia en investigación o Se valora experiencia previa en NHS/experiencia en prácticas y sistemas de NHS • Entendimiento de gestión de riesgo clínico y gestión general clínica • Capacidad para tomar decisiones clínicas independientes cuando sea necesario y capacidad para buscar consejo de doctores senior cuando sea apropiado • Capacidad para gestionar el propio tiempo y carga de trabajo • Experiencia en evaluación de emergencias • Capacidad de trabajo como miembro de un equipo o de forma independiente • Excelentes habilidades de comunicación – habilidad para tratar con tacto al paciente/relativos y personal • Habilidad de enseñanza • Flexible y adaptable a las demandas • Carnet de conducir/capacidad para movilizarse • Capacidad para hacer guardias • Compromiso con prácticas nuevas ESPECIALISTA URGENCIAS Nº Vacantes: 3 País: Wales, UK Salario: £36,807 - £68,638 Requerimientos mínimos: • 4 años de experiencia, y al menos 2 en campo de urgencias (emergencias y accidentes) • Inglés C1 o C2 GERIATRA

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Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012 Nº Vacantes: 1 País: Wales, UK Salario: £36,807 - £68,638 Requerimientos mínimos: • Geriatra con 4 años de experiencia, y al menos 2 como geriatra • Inglés C1 o C2 • Experiencia: o Experiencia trabajando de forma efectiva como parte de equipo multidisciplinario o Algo de experiencia endoscópica o Compromiso con trabajo en equipo y disciplinario o Se valora experiencia como parte de equipo de dirección o Coordinación con otras agencias u organismos o Educación y entrenamiento de personal médico graduado y no graduado o Se valora iniciación, progreso y cumplimentación de auditorías o Se valora capacidad experiencia en investigación o Se valora experiencia previa en NHS/experiencia en prácticas y sistemas de NHS • Entendimiento de gestión de riesgo clínico y gestión general clínica • Capacidad para tomar decisiones clínicas independientes cuando sea necesario y capacidad para buscar consejo de doctores senior cuando sea apropiado • Capacidad para gestionar el propio tiempo y carga de trabajo • Experiencia en evaluación de emergencias • Capacidad de trabajo como miembro de un equipo o de forma independiente • Excelentes habilidades de comunicación – habilidad para tratar con tacto al paciente/relativos y personal • Habilidad de enseñanza • Flexible y adaptable a las demandas • Carnet de conducir/capacidad para movilizarse • Capacidad para hacer guardias • Compromiso con prácticas nuevas JEFE DE ANESTESIA OBSTETRICA - UK Nº Vacantes: 2 País: Gales, UK Salario: £74,504 - £100,466 Requerimientos mínimos: • Anestesista con 7 años de experiencia en anestesia • Inglés C1 o C2 • Experiencia o Efectividad de trabajo como parte de un equipo multidisciplinario o Se valora experiencia en equipo directivo o Coordinación con otras agencias u organismos o Experiencia en investigaciones o Capacidad para asesorar un funcionamiento eficiente de especialistas, capacidad de organización, gestión y priorización de la carga de trabajo o Educación y entrenamiento de personal médico graduado y no graduado o Iniciación, progreso y cumplimentación de auditorías o Se valora capacidad para aplicar resultados de investigación a problemas clínicos o Se valora experiencia previa en NHS/experiencia en prácticas y sistemas de NHS • Habilidades de liderazgo y trabajo en equipo • Excelentes habilidades de comunicación – habilidad para tratar con tacto al paciente/relativos y personal • Habilidad de enseñanza • Entendimiento de sistemas tecnológicos y de la información. • Se valora interés en anestesia obstétrica

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Boletín Informativo

Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012 • Flexible y adaptable a las demandas • Carnet de conducir/capacidad para movilizarse • Capacidad para hacer guardias • Compromiso con prácticas nuevas • Capacidad para adquirir rol de liderazgo en el desarrollo clínico • Se valoran otros grados/diplomas relevantes JEFE DE ANESTESIA - UK Nº Vacantes: 1 País: Gales, UK Salario: £74,504 - £100,466 Requerimientos mínimos: • Anestesista con 7 años de experiencia en anestesia • Inglés C1 o C2 • Experiencia o Efectividad de trabajo como parte de un equipo multidisciplinario o Se valora experiencia en equipo directivo o Coordinación con otras agencias u organismos o Experiencia en investigaciones o Capacidad para asesorar un funcionamiento eficiente de especialistas, capacidad de organización, gestión y priorización de la carga de trabajo o Educación y entrenamiento de personal médico graduado y no graduado o Iniciación, progreso y cumplimentación de auditorías o Se valora capacidad para aplicar resultados de investigación a problemas clínicos o Se valora experiencia previa en NHS/experiencia en prácticas y sistemas de NHS • Habilidades de liderazgo y trabajo en equipo • Excelentes habilidades de comunicación – habilidad para tratar con tacto al paciente/relativos y personal • Habilidad de enseñanza • Entendimiento de sistemas tecnológicos y de la información. • Flexible y adaptable a las demandas • Carnet de conducir/capacidad para movilizarse • Capacidad para hacer guardias • Compromiso con prácticas nuevas • Capacidad para adquirir rol de liderazgo en el desarrollo clínico • Se valoran otros grados/diplomas relevantes JEFE DE MEDICINA (CARDIOLOGÍA) - UK Nº Vacantes: 1 País: Gales, UK Salario: £74,504 - £100,466 Requerimientos mínimos: • Cardiología con 7 años de experiencia en cardiología • Inglés C1 o C2 • Experiencia o Efectividad de trabajo como parte de un equipo multidisciplinario o Se valora experiencia en equipo directivo o Coordinación con otras agencias u organismos o Experiencia en investigaciones o Capacidad para asesorar un funcionamiento eficiente de especialistas, capacidad de organización, gestión y priorización de la carga de trabajo

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Boletín Informativo

Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012 o Educación y entrenamiento de personal médico graduado y no graduado o Iniciación, progreso y cumplimentación de auditorías o Se valora capacidad para aplicar resultados de investigación a problemas clínicos o Se valora experiencia previa en NHS/experiencia en prácticas y sistemas de NHS • Habilidades de liderazgo y trabajo en equipo • Excelentes habilidades de comunicación – habilidad para tratar con tacto al paciente/relativos y personal • Habilidad de enseñanza • Entendimiento de sistemas tecnológicos y de la información. • Flexible y adaptable a las demandas • Carnet de conducir/capacidad para movilizarse • Capacidad para hacer guardias • Compromiso con prácticas nuevas • Capacidad para adquirir rol de liderazgo en el desarrollo clínico • Se valoran otros grados/diplomas relevantes JEFE DE MEDICINA (GERIATRÍA) - UK Nº Vacantes: 1 País: Gales, UK Salario: £74,504 - £100,466 Requerimientos mínimos: • Geriatra con 7 años de experiencia en geriatría • Inglés C1 o C2 • Experiencia o Efectividad de trabajo como parte de un equipo multidisciplinario o Se valora experiencia en equipo directivo o Coordinación con otras agencias u organismos o Experiencia en investigaciones o Capacidad para asesorar un funcionamiento eficiente de especialistas, capacidad de organización, gestión y priorización de la carga de trabajo o Educación y entrenamiento de personal médico graduado y no graduado o Iniciación, progreso y cumplimentación de auditorías o Se valora capacidad para aplicar resultados de investigación a problemas clínicos o Se valora experiencia previa en NHS/experiencia en prácticas y sistemas de NHS • Habilidades de liderazgo y trabajo en equipo • Excelentes habilidades de comunicación – habilidad para tratar con tacto al paciente/relativos y personal • Habilidad de enseñanza • Entendimiento de sistemas tecnológicos y de la información. • Flexible y adaptable a las demandas • Carnet de conducir/capacidad para movilizarse • Capacidad para hacer guardias • Compromiso con prácticas nuevas • Capacidad para adquirir rol de liderazgo en el desarrollo clínico • Se valoran otros grados/diplomas relevantes JEFE DE RADIOLOGÍA - UK Nº Vacantes: 3 País: Gales, UK Salario: £74,504 - £100,466 Requerimientos mínimos: • Radiólogo con 7 años de experiencia en radiología • Inglés C1 o C2

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Boletín Informativo

Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012 • Experiencia o Efectividad de trabajo como parte de un equipo multidisciplinario o Se valora experiencia en equipo directivo o Capacidad para asesorar un funcionamiento eficiente de especialistas, capacidad de organización, gestión y priorización de la carga de trabajo o Se valora capacidad para ofrecer opinión clínica experta en emergencias dentro de la especialidad. Capacidad para tener responsabilidad completa e independiente para el cuidado clínico de los pacientes. Interés en complementar a los actuales jefes o Educación y entrenamiento de personal médico graduado y no graduado o Iniciación, progreso y cumplimentación de auditorías o Se valora capacidad para aplicar resultados de investigación a problemas clínicos o Se valora experiencia previa en NHS/experiencia en prácticas y sistemas de NHS • Habilidades de liderazgo y trabajo en equipo • Excelentes habilidades de comunicación – habilidad para tratar con tacto al paciente/relativos y personal • Habilidad de enseñanza • Se valora Interés en radiología de pecho • Flexible y adaptable a las demandas • Carnet de conducir/capacidad para movilizarse • Capacidad para hacer guardias • Compromiso con prácticas nuevas • Capacidad para adquirir rol de liderazgo en el desarrollo clínico • Se valoran otros grados/diplomas relevantes candidatos@binternational.es

Oferta de trabajo en Londres

The North West London Hospitals NHS Trust, un grupo de hospitales públicos, necesita médicos de emergencias para trabajar en Londres. Se buscan médicos especialistas en medicina de urgencias y en curso de especialidad. El contrato sería de dos años y se requiere un nivel alto de inglés. La persona de contacto es Teena Ferguson. Email: Teena.ferguson@nhs.es Teléfono: 0034664365714 o 00442088695205

Oferta de trabajo en Castellón Se necesita un Facultativo Especialista en Urología, preferiblemente formado vía MIR, para el Hospital de Vinarós. El puesto de trabajo sería a jornada completa, incluyendo guardias. Email. forner_luc@gva.es Teléfono: 964477014

El Hospital Reina Sofía de Tudela (Navarra) necesita un facultativo especialista en Ginecología y otro facultativo especialista en Traumatología. El contrato es de seis meses con incorporación inmediata en un hospital comarcal con 168 camas. Ambos servicios los componen 11 profesionales y se realizarán guardias de presencia física y localizada. Los interesados pueden informarse en el teléfono 848434110 o por correo electrónico: hrst@navarra.es

OFERTA DE TRABAJO MÉDICO/A de ADECCO MEDICAL & SCIENCE

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Boletín Informativo

Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012 SALAMANCA, Adecco Medical & Science, consultora líder especializada en la búsqueda y selección de perfiles de las áreas Sanitaria, Científica, Farmacéutica y Preventiva, selecciona Médico/a Asistencial para la provincia de Salamanca Se requiere: - Licenciatura en Medicina - Homologación y permiso de trabajo en caso de profesional extranjero - Valorable experiencia mínima de un año. Se ofrece: - Compatibilidad con otro trabajo DATOS DE CONTACTO Interesados enviar CV a esther.chamorro@adecco.com ó miriam.pelaz@adecco.com Ó bien llamar al 983 36 05 95

Centro de reproducción asistida ubicado en Sevilla, oferta puesto de ginecólogo/a especialista Centro de reproducción asistida ubicado en Sevilla, oferta puesto de ginecólogo/a especialista (Se requiere título de especialista vía MIR u homologado), no es necesario acreditar experiencia en clínicas/centros de fertilidad. Se oferta contrato laboral a tiempo completo o en modalidad freelance. Condiciones a negociar con el candidato. Interesados enviar CV a: rrhh@bionac.eu

NUEVAS OPORTUNIDADES PARA MEDICOS EN EL REINO UNIDO GlobalMediRec ofrece nuevas oportunidades para los médicos en Hospitales en el NHS (Servicio de Salud Pública) en el Reino Unido. Actualmente estamos buscando: 4 Medicos Especialistas en Geriatria Se trata de puestos de trabajo permanentes a tiempo completo, con 1 año de contrato inicial. El sueldo es de entre £ 74.000 y £ 101000 libras al año para las horas de trabajo no excederá de 37½ horas a la semana (+ guardias). Los Hospitales están en el norte Londres,e Manchester cerca al aeropuerto, que es un excelente lugar para el regreso en españ para el fin de semana: iniciará vuelos directos de bajo coste a los principales aeropuertos españolos. GlobalMediRec concertar entrevistas telefónicas, asistencia para el registro de GMC (Colegio Médicos Inglés), y toda la logística de trasladar al Reino Unido. La asistencia de GlobalMediRec es completamente GRATIS por los medicos Para más información, favor de enviar su Curriculum Vitae a: Emma Keeler Head of International Resourcing – GlobalMediRec emmakeeler@ globalmedirec.com +44 203 2392699 +44 7881 590203

Ofertas de empleo de Hertfordshire Partnership NHS Foundation Trust Hertfordshire Partnership NHS Foundation Trust es una organización en constante crecimiento que busca experimentados, entusiastas, flexibles y comprometidos doctores en un amplio rango de especialidades, dentro de las que se destacan las siguientes:

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Boletín Informativo

Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012

· Psiquiatría General en Adultos y Geriátrica · Problemas de Aprendizaje · Forense · Salud mental en niños y adolescentes El rango salarial varia entre 45.000€ y 80.000€S dependiendo de la experiencia previa, mas excelentes beneficios. El proceso de selección tendrá lugar en Valencia, España los días 13 y 14 de Julio para aquellos candidatos que hayan pasado la entrevista previa por Skype. Para mas información acerca de las oportunidades que ofrecemos y para ser tenido en cuenta para el proceso de selección, por favor enviar CV en ingles, formato Word, titulado “Doctor for the UK” a la siguiente dirección: carlos.perez@bestpersonnel.ie Carlos Perez 3 Sandyford Office Park, Sandyford, Dublin E-mail: carlos.perez@bestpersonnel.ie http://bestpersonnelpt.webs.com www.facebook.com/BESTPERSONNEL

Grupo Clave Servicios Empresariales selecciona Director Médico del Trabajo para importante empresa de ámbito nacional con sede en Lugo. Requisitos mínimos: • Licenciado/a en Medicina, especialidad en Medicina del Trabajo. • Imprescindible experiencia mínima en puesto similar de al menos 5 años. • Disponibilidad para viajar a nivel nacional. • Fijar residencia en Lugo. • Trabajo en equipo y orientado a resultados. • Organizar y dirigir un equipo de trabajo. Funciones del puesto • • • • •

Analizar la situación de las delegaciones nacionales a su cargo. Supervisión, control y coordinación de la actividad desarrollada por el Área Médica de las Delegaciones. Proponer las Acciones Correctoras necesarias para conseguir los objetivos planificados. Realizar el seguimiento de los planes de actuación a nivel nacional. Transmitir la política y criterios médicos de la Compañía.

Interesados/as envíen CV a las siguientes direcciones de correo electrónico: - formacionclave@grupoclave.es - comercial@grupoclave.es

Fundación de Hemoterapia y Hemodonación de Castilla y León BUSCA LICENCIADOS EN MEDICINA PARA TRABAJAR EN SEGOVIA Y PROVINCIA Y EN CASTILLA Y LEON

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Edición Nº 10 Semana del 1ª Quincena de diciembre de 2012

OFRECEMOS: • Trabajo como Médico de Colectas para sustituciones de vacaciones de verano y fechas puntuales en Segovia y/o provincia. Y en varias provincias de la Comunidad de Castilla y León. • Retribución muy interesante. • Formación a cargo del Centro de Hemoterapia y Hemodonación de Castilla y León. • Se valorará carné de conducir B y disponibilidad de vehículo propio. INTERESADOS • Ponerse en contacto con el Centro de Hemoterapia y Hemodonación de Castilla y León. Paseo Filipinos s/n. 47007 Valladolid. • Tfno. 983 10 16 80 de 9:00 a 14:00 de lunes a viernes • E-mail: sfernandezfe@saludcastillayleon.es

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Anexos A continuación figuran los documentos anexos a los artículos e informaciones del boletín.

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Foto portada por ValentĂn Guisande: Nacimiento (detalle) Los pastores de BelĂŠn (detalle) AdoraciĂłn de los Magos (detalle) Iglesia de Santo Domingo. Siglo XII (Soria)

PROFESIÓN MÉDICA Y REFORMA SANITARIA Propuestas para una acción inmediata

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Diciembre, 2012

PRESENTACION

La elaboración del texto que hoy se presenta en Galicia se llevó a cabo a lo largo de los meses de mayo y junio de este mismo año 2012. El documento responde a una petición del Presidente de la Xunta de Galicia D. Alberto Núñez Feijoo al Presidente del Consejo General de Colegios Médicos de España (CGCOM) D. Juan José Rodriguez Sendin, interesado aquel en conocer el punto de vista de la profesión médica en relación a las tensiones por las que está atravesando la sanidad pública en nuestro país. El Presidente del CGCOM encargó a su vez la redacción a diez profesionales, la mayor parte de los cuales no ostenta representación institucional alguna y muchos de ellos con actividad clínica asistencial.

En el estado actual de la crisis por la que atraviesa nuestro país seis meses es mucho tiempo. Lo que significa que desde la conclusión de la versión definitiva

hasta

momento

presente

han

sucedido

importantes

acontecimientos: han aparecido nuevas normas con sus correspondientes desarrollos, se han revisado a la baja los presupuestos, modificado algunas condiciones laborales, salarios incluidos, y la sociedad y los representantes profesionales se han pronunciado en uno u otro sentido. Y es previsible que se sucedan medidas en relación con los medicamentos, tanto las que se refieren a una mayor convergencia con otros estados miembros en la participación del usuario como al énfasis en los análisis de coste-efectividad sobre nuevos fármacos. Propuestas legítimas, pero que deben argumentarse y explicarse. Lo que, por cierto, no se ha hecho con la reciente e improvisada formulación de unas reformas discutibles en algunas Comunidades Autónomas y que están recibiendo una fuerte contestación profesional.

También hay que decir que se ha maniobrado con acierto para acotar los

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como la Xunta de Galicia, pactando con los colectivos afectados, han conseguido

efectos negativos de algunas medidas. En este sentido, algunas administraciones

minimizar el impacto de la retirada de la asistencia a personas en riesgo de exclusión. Con ello se demuestra que incluso en momentos de extraordinaria dificultad, los principios –y consensos- básicos sobre los que se asienta nuestro sistema sanitario no sólo deben sino que pueden ser preservados.

En el documento se mencionan “líneas rojas” que no deben sobrepasarse cuando el gasto sanitario se vuelva a revisar anualmente, si no se quiere provocar un deterioro irreversible en la calidad de los servicios prestados. Con independencia de la dificultad de fijar con absoluta exactitud una cifra concreta y que ha de basarse en estimaciones, todo el mundo concuerda en que lo que es exigible en primer lugar es la revisión de las actividades inadecuadas y/o innecesarias. Sin embargo, los trabajos para identificar las mismas se están llevando a cabo con tal premiosidad que se corre un serio riesgo de seguir podando por lo más fácil y no por lo menos importante.

La respuesta sostenible y eficiente a la crisis financiera en la sanidad, exige cambios estructurales y de estrategias; pero los recortes lineales bloquean estos cambios e imponen reducciones que no sólo afectan a lo prescindible si lo hubiera, sino que también a lo imprescindible para mantener la calidad de los servicios sanitarios.

La única forma de hacer economías selectivas que promuevan la sostenibilidad interna del Sistema Nacional de Salud es revitalizando la alianza con los profesionales y utilizando instrumentos de gestión y gobierno clínico. Pero el ambiente creado por muchas políticas extemporáneas cuando no hostiles, no es el más favorable para establecer estas vías fluidas de diálogo. No obstante lo anterior, la posición de la Organización Médica Colegial es inequívoca; toca hablar y buscar soluciones reales asi como comprometerse en su puesta en

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práctica.

En la base de todas las propuestas efectuadas late la exigencia de dar un protagonismo efectivo y de mayor alcance a la profesión médica. El liderazgo médico, una forma mayor de protagonismo, por así decirlo, no se traduce en la demanda de generar mayor confusión y ruido a través de la multiplicación de órganos asesores. De hecho, la mayor parte de órganos asesores en los que intervienen los médicos apenas son escuchados y, como mucho, reciben algunas explicaciones. Por otro lado, como se suele decir coloquialmente, ni están todos los que son ni son todos los que están. Conviene estudiar las fórmulas más eficaces para que ese liderazgo de la profesión médica exista realmente y no provoque desconfianza ni impida la fluidez en la toma de decisiones sino todo lo contrario. La profesión apuesta por esta vía.

Este trabajo se presenta en Galicia, y no es por casualidad. Es de justicia señalar el esfuerzo que está llevando a cabo la Xunta de Galicia para, de manera respetuosa con las decisiones que se toman en otros niveles de la administración, provocar la menor distorsión posible en el funcionamiento de los servicios sanitarios. Últimamente, en Galicia se han llevado a cabo valiosas iniciativas que van desde la introducción de mayor racionalidad en el uso de los medicamentos, algo en que los médicos aún pueden seguir colaborando, hasta un mayor esfuerzo por adoptar un enfoque más sensible con las necesidades de la profesión. Pasando por la expansión en el uso de los sistemas de información con el objetivo –y de momento incluso con algunos resultados- de incrementar la eficiencia del sistema sanitario. Mejorar la eficiencia es garantizar la sostenibilidad en la aciaga situación por la que atravesamos. La profesión médica considera una oportunidad contar con la interlocución de un Gobierno sensible y confía en la generalización de esta actitud.

Por último cabe decir que se trata, como no podría ser de otra manera, de un documento crítico. Quizá la mayor recriminación se hace a la incapacidad de

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pública como terreno propicio para ponerse zancadillas. Por eso se solicita

los representantes políticos a corregir su tendencia a usar –y abusar- de la sanidad

reiteradamente, aunque con menguada esperanza, que se rectifique y se pacte lo fundamental. No es obligatorio estar de acuerdo con todo lo que se dice pero queremos resaltar que se trata de un texto redactado de buena fe y con espíritu constructivo. Las administraciones públicas no deben esperar de sus interlocutores sociales –y, desde luego, no de la profesión médica- manifestaciones acríticas de mera adhesión inquebrantable a políticas partidarias. Sería una pérdida de tiempo para quien las formulara y aún sería peor para quien las recibiera, que de esa forma se privaría de una oportunidad de calibrar correctamente sus decisiones de cara al interés general. En el diseño de políticas públicas, la participación implica tensiones, con frecuencia salpicadas de errores y contradicciones, pero lo que ha animado al Consejo General de Colegios Oficiales de Médicos a manifestar su deseo de colaboración es su irrenunciable voluntad de hacerse escuchar y al tiempo de ser útil y responsable.

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Juan Jose Rodriguez Sendin Presidente Consejo General de Colegios Oficiales de Médicos

PROFESIÓN MÉDICA Y REFORMA SANITARIA Propuestas para una acción inmediata

Capítulo I

EL SNS: FINANCIACIÓN Y SOSTENIBILIDAD

Capítulo II

LA NECESIDAD DE UN GRAN ACUERDO POLÍTICO

Capítulo Capítulo III

GESTIÓN Y BUEN GOBIERNO DE CENTROS Y SERVICIOS SANITARIOS PÚBLICOS.

Capítulo IV

PROFESIÓN

MÉDICA:

MÉDICO

QUE

NECESITAMOS:

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PROPUESTAS

Capítulo I

EL SNS: FINANCIACION Y SOSTENIBILIDAD

I.1 Marco de referencia:

El llamado Sistema Nacional Nacional de Salud español (SNS) es el resultado de un complejo proceso histórico, a lo largo del cual se ha ido produciendo una migración progresiva de un modelo vinculado a la Seguridad Social y financiado por cuotas, hacia otro inspirado en los Servicios Nacionales de Salud de orientación poblacional y financiado por impuestos. Además, este proceso se ha acoplado con una descentralización de competencias y financiación a las Comunidades Autónomas (CCAA), que han recibido la transferencia de la inmensa mayoría de establecimientos de titularidad pública de las diferentes administraciones (la Seguridad Social retiene el patrimonio en los suyos). Desde enero de 2002, las CCAA se configuran como la administración territorial especializada en la gestión de servicios de bienestar social tan importantes como la sanidad, la educación y los servicios sociales; la sanidad es el que mayor peso económico tiene, con cerca del 40% del presupuesto de gastos.

Los consensos políticos para la construcción del SNS no han sido fáciles. La Ley General de Sanidad de 1986 promovida por el PSOE (Ministro Ernest Lluch), fue políticamente convalidada por el Partido Popular (Ministro José Manuel Romay) en 1998, cuando el dictamen de la Subcomisión Parlamentaria de mejora y racionalización del Sistema Nacional de Salud dio por válida la arquitectura institucional del SNS. Esta convergencia entre los dos partidos

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transferencia plena del INSALUD en enero de 2002, y b) con el nuevo modelo

mayoritarios incorpora las expectativas nacionalistas y regionalistas: a) con la

de la Ley 21/2001 que otorga una financiación no finalista a las CCAA y una amplia autonomía por el lado de los gastos para gestionar el conjunto de servicios transferidos. Este amplio consenso se plasmó en la aprobación en 2003 de la Ley 16/2003 de Cohesión y Calidad del SNS, promovida por la Ministra Ana Pastor, que intenta aportar instrumentos de coordinación de un SNS con una arquitectura extremadamente descentralizada.

En relación a la cobertura del SNS, SNS La conciencia mayoritaria de la sociedad española avaló cada paso de la extensión de la acción protectora sanitaria de la Seguridad Social, incluidas las personas sin recursos (Real Decreto 1088/89), y tras la reforma promovida por el gobierno de Aznar con la Ley Orgánica

4/2000

extranjería,

extendida

aquellos

inmigrantes

empadronados.

Un eje de consenso menor fue la reforma de las formas de gestión de las instituciones sanitarias, y el modelo de vinculación de personal (ambos temas estrechamente ligados).

En lo referido a las formas de gestión de los centros sanitarios públicos, públicos era ampliamente compartido el diagnóstico de que el modelo administrativo y funcionarial para la gestión de servicios complejos de tipo profesional (sanidad) no era el más apropiado. Pero en las alternativas había menor consenso. En lo referido al modelo de vinculación de personal, personal el debate entre laboralización o funcionarización ocupó una década, durante la cual se fueron paralizando los concursos, y se acumularon y enquistaron situaciones de interinidad y contrataciones eventuales y precarias

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insostenibles.

En la práctica, todos los debates suscitados desde el Informe Abril de 1991, tanto en el dilema laboralización/funcionarización, como en las experiencias de consorcios, fundaciones y empresas públicas, se saldaron en un texto legal (Ley 15/1997 de habilitación de formas de gestión), una orientación de facto de la vinculación estatutaria (vía OPE extraordinaria de la Ley 16/2001 para consolidación de personal), y el tardío Estatuto Marco del personal (Ley 55/2003), cuyas holguras han sido reinterpretadas a nivel central y autonómico en clave funcionarizante.

La aplicación de cambios fue tímida, incompleta y limitada. En la práctica, las innovaciones en gestión institucional y de personal se han puesto en marcha en centros o servicios de nueva creación, creando un sistema dual de centros sanitarios con modelo administrativo (de tamaño grande y mediano), y otros con modelos asimilables a empresas o entes públicos (con tamaños menores).

El consenso en innovar la

gestión pública, no consiguió implicar ni a

Izquierda Unida, ni a los sindicatos CCOO y UGT; tampoco consiguió entusiasmar a los sindicatos profesionales. Desde 1999, se produce una mayor divergencia con el desarrollo en la Comunidad Valenciana de alternativas de concesión de la asistencia sanitaria pública a empresas privadas (que luego se extendió a Madrid y otras CCAA en diferentes variantes de la “colaboración público-privada”). La externalización ha sido un eje permanente de controversia política, sindical, profesional y social, y ha limitado las posibilidades de cristalizar un acuerdo amplio de reformas institucionales.

Por todo lo anterior, la construcción del SNS fue acumulando una serie de debilidades institucionales institucionales, nales y sorteando en cada etapa la necesidad de acometer reformas estructurales que estaban razonablemente identificadas; la incapacidad política e institucional para gestionar cambios, se acompañó tras 1996 de una

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expandir el sistema y evitó enfrentarse a los verdaderos problemas. La crisis

larga etapa de crecimiento económico que disipó las tensiones y permitió

económica iniciada en 2008 ha supuesto una ruptura abrupta en la trayectoria histórica, que evidencia las debilidades institucionales y está suponiendo un riesgo importantísimo para la sostenibilidad del SNS. La opción planteada por el Gobierno, expresada en el Real Decreto Ley 16/2012, inicia una senda contraria al lento avance experimentado en los consensos básicos que han conformado la trayectoria histórica del SNS.

I.2 Datos comparativos:

Como complemento al marco de referencia, adjuntamos las siguientes figuras que facilitan la comprensión de los aspectos financieros del SNS:

En la figura 1 se evidencia la conocida situación de costes económicos razonables del SNS español, cuando lo comparamos con los demás países de la OCDE (España suele comportarse como valor medio de la UE-27, y con un gasto sanitario notablemente menor frente a los países de la UE-15).

Figura 1: 1 Cuadro comparativo de Gasto Sanitario per cápita (público y privado) en dólares (ajustados por paridad de compra) entre países de la OCDE

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http://www.oecd.org/dataoecd/6/28/49105858.pdf: Página 151.

en el año 2009. Tomado de Health at a Glance 2011 - OECD INDICATORS:

Pero, como se observa en la figura 2, 2 el ritmo de crecimiento entre 2000 y 2009 fue superior al del PIB (2,5 veces más rápido), siendo el doble en el caso español (5 veces mayor el crecimiento del gasto sanitario que el crecimiento del PIB); sólo cuatro países europeos superaron a España: Dinamarca, Bélgica, Italia e Irlanda. La pregunta es si en esta fase de crecimiento acelerado los incrementos se aplicaron de forma suficientemente racional.

Figura 2: 2 Tasa anual de crecimiento en gasto sanitario per cápita, 20002009 (abscisas) relativo al crecimiento del PIB (ordenadas) en países de la OCDE: línea inferior (azul) crecimiento igual que el PIB; línea media (roja), pendiente crecimiento OCDE; línea verde, pendiente de crecimiento de España. Tomado y modificado

Health

Glance

2011

OECD

INDICATORS:

http://www.oecd.org/dataoecd/6/28/49105858.pdf: página 151

En la figura 3 se evidencia para el gasto sanitario público en el período 2002-2008 la evolución de los incrementos interanuales: en la mayoría de anualidades un punto superior el crecimiento del gasto sanitario público; pero en

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del inicio de la crisis económica (2008/2007), se aprecian notables diferencias

el año de la transferencia sanitaria completa del INSALUD (2003/2002) y en el

entre ambas tasas de crecimiento a favor del gasto sanitario público.

Figura 3: 3 evolución del crecimiento interanual del PIB y del Gasto Sanitario Público en el período 2002-2008; Fuente: estadísticas de gasto sanitario / Ministerio de Sanidad, Servicios Sociales e Igualdad; elaboración propia.

El largo período de crecimiento en

la financiación sanitaria pública,

supuso incrementos en los recursos humanos del sistema; en la figura 4 se compara para los hospitales de titularidad pública (tamaño medio de 420 camas) el crecimiento porcentual de recursos humanos (51% médicos y 38% enfermeras) comparado con el incremento de una parte relevante de la actividad asistencial (33% de aumento en la suma de altas e intervenciones por Cirugía Mayor Ambulatoria). Es de justicia mencionar que la complejidad de casuística puede estimarse que creció en torno a un 12% (como efecto del envejecimiento o porque la red de grandes y medios hospitales públicos concentrara los casos

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más complejos).

Figura 4: 4 Incremento en 12 años de médicos, enfermeras, y actividad (altas+CMA) en hospitales de titularidad pública. Fuente ESCRI y datos estudio OMC – Demografía Médica 2011

En la figura 5, 5 vemos el efecto de la crisis económica, a través del presupuesto por persona protegida por las CCAA; el presupuesto es una magnitud que no coincide con el gasto liquidado ni con el gasto real, pero es la única magnitud que tenemos con fechas actuales para reseñar la evolución de los últimos tres años. Tras 2009, donde se llega al pico de 1261 €, se inicia el

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Figura 5: 5 evolución de los presupuestos iniciales de las CCAA, expresados

descenso que en 2011 llega a 1.229 €.

en forma de presupuesto por persona protegida, desde 2007 hasta 2011. Tabla tomada de estudio del Ministerio de Sanidad, Servicios Sociales e Igualdad y modificada para presentación. http://www.msps.es/estadEstudios/estadisticas/inforRecopilaciones/docs/Recursos _Red_2011.pdf

Y, finalmente, en la figura 6, 6 se expone la expectativa del gobierno en Mayo 2012 de llevar el gasto sanitario público del 6,5 (% del PIB) existente en 2010, a un 5,1 % en 2015 (reducción de la participación de la sanidad en la riqueza nacional de un 21,3% de los gastos en 5 años escasos).

Figura 6: 6 Escenario de reducción del peso de gasto sanitario público en relación al PIB 2010-2015 dentro de la actualización del Programa de Estabilidad de España(Mayo 2012).http://www.lamoncloa.gob.es/NR/rdonlyres/8A9ED6BD9183-41EA-A8AC-4DA56487D8E/202009/ActualizacinProgramaEstabilidad2.pdf

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Cabe hablar de cuatro grandes problemas, que surgen de la conjunción de

I.3 Identificación de problemas:

la crisis económica con los problemas estructurales y las debilidades institucionales del SNS.

1) Problemas de suficiencia presupuestaria: presupuestaria en la historia de la sanidad pública española, cabría hablar de una infra-presupuestación estructural, por la cual en muchas anualidades se partía de dotaciones económicas a la baja respecto a las proyecciones de gasto. Esto ha llevado a devaluar los presupuestos como instrumentos de gestión, y a requerir cada cuatro o cinco años operaciones de saneamiento

para pagar las deudas

acumuladas. A esto se ha añadido el efecto de la crisis sobre los Ingresos Tributarios del Estado, la tardanza en comenzar las operaciones de ajuste, y la amplitud y rapidez de los recortes en el gasto sanitario público que se plantean desde el año 2011.

La sanidad se basa en activos altamente específicos (profesionales, tecnologías, centros…) que no se benefician de crecimientos rápidos: la expansión acelerada del 2002 al 2009 mostró que una cosa era construir centros y otra dotarlos de especialistas cualificados. Pero, también, que no cabe hacer reducciones por encima del 3-4% anual sin que ello suponga una destrucción de dichos activos y la erosión de la funcionalidad de los centros y servicios sanitarios.

La contención del gasto sanitario sanitario público puede y debe hacerse desde la inteligencia profesional y gestora. gestora Los cambios estructurales orientados a la gestión del conocimiento y a la desinversión en lo que no añade valor, son estrategias de relevancia fundamental para la racionalización de la asistencia. Los recortes en personal, prestaciones y en cobertura a inmigrantes plantean enormes dilemas éticos a la profesión médica, que no puede aceptar sin más un cambio en la misión y vocación universalista

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del Sistema Nacional de la Salud.

La reciprocidad con transeúntes, turistas o residentes de otros países parece un principio lógico y razonable. No parece tan fácil aplicarlo cuando hablamos de inmigrantes de lugares donde los Estados son frágiles, el poder es despótico, y las economías sólo permiten la subsistencia. En todo caso, las políticas de control de la inmigración son las que deben materializar la voluntad de la sociedad en el grado de acogida y regularización de inmigrantes. Pero, una vez que están dentro de España, no deben ser los médicos ni los sanitarios los que se vean ante el dilema ético de racionar o dosificar la prestación asistencial. Por otra parte, limitar la atención primaria y dejar sólo la puerta de urgencias, es una forma escasamente inteligente de abordar el reto, desde la perspectiva clínica y de salud pública.

Hay alternativas para la suficiencia y la sostenibilidad que pueden articularse si se limita la compulsión y se establece un marco temporal razonable, y unos instrumentos de diálogo político, institucional, profesional, sindical y social que permitan a todas las partes implicadas expresar sus ideas y formalizar sus compromisos

2) Problemas de cierre del modelo de universalización y definición positiva de “ciudadanía sanitaria”; en efecto: no hay una definición en positivo del SNS ni de su gobierno colegiado; ni tampoco del concepto de cobertura universal y ciudadanía sanitaria. Parece contradictorio que un sistema financiado por impuestos pueda negar la extensión de cobertura a personas con recursos que sin embargo no acreditan cotización a la Seguridad Social. Por otra parte, los extranjeros sin recursos y que viven en España sin registro ni autorización, no pueden estar a extramuros de la asistencia integral y programada del SNS, tanto por razones bioéticas, como de efectividad clínica y preventiva. Los cambios planteados en el

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profundizar en el concepto de ciudadanía sanitaria del SNS, retroceden a

Real Decreto Ley 16/2012 no van por el camino correcto, correcto pues en vez de

una definición Bismarckiana de aseguramiento vinculado a cotización o prestaciones de la Seguridad Social, y vuelven a otorgar al Instituto Nacional de la Seguridad Social un papel determinante en la definición y clasificación de asegurados y beneficiarios.

3) Problemas de Buen Gobierno y Buena Gestión: Gestión la debilidad de las reglas institucionales facilita el comportamiento oportunista de los agentes. Se transfieren obligaciones a las CCAA sin que la financiación sea suficiente en muchos casos; pero el ciclo expansivo de la economía alimenta una alianza de todos los agentes (incluido el entramado industrial tecnofarmacéutico) a favor del crecimiento en centros, servicios, plantillas, salarios y prestaciones, que supera ampliamente la capacidad de financiación establecida en el modelo de la Ley 21/2001. Los sistemas de colaboración público-privada permiten hacer más hospitales y demorar el pago a la siguiente legislatura y a las generaciones venideras; la no contabilización de pagos a proveedores de tecnología y medicamentos embalsa la deuda para futuras operaciones de saneamiento; y de esta manera se prepara el colapso de financiación de 2010. No es gobierno: con el estrictamente un problema económico, sino de mal gobierno crecimiento indexado al PIB y una reflexión más racional sobre la expansión de centros y servicios, se podría haber ajustado una trayectoria de mejora de los servicios a medio plazo, contando con la racionalización de desarrollar los cambios estructurales y de gestión necesarios. La propia crisis financiera internacional, en último término tiene también una génesis en el mal gobierno de los bancos, las entidades de crédito, los fondos de inversión y las agencias de auditoría y rating. Por eso la salida a la sostenibilidad del SNS requiere encontrar una senda virtuosa para que el Buen Gobierno y la Buena Gestión minimicen los riesgos de que la

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4) Problemas de subdesarrollo de la Gestión Clínica, la Integración Asistencial

necesaria autonomía gestora devenga en arbitrariedad.

y el Profesionalismo Profesionalismo como alternativa de cambio estructural del SNS.

En la gran mayoría de países desarrollados desde hace una década se está trabajando en un cambio estructural de la medicina y los sistemas sanitarios, sanitarios a partir de elementos bien conocidos como la medicina basada en la evidencia, la gestión del conocimiento, la gestión clínica, la departamentalización de hospitales, el trabajo por procesos integrados, las estrategias de cronicidad, la coordinación socio-sanitaria, etc. La debilidad de los recursos de media y larga estancia, y de atención a la dependencia hacen muy importante la activación de todos los mecanismos que potencien la activación de recursos sociales desde el sector sanitario.

También ha habido un cambio en el paradigma de gestión: gestión de modelos que transitaron entre la jerarquía de base administrativa y el gerencialismo de corte industrial, se ha pasado a reconocer que la sanidad es una organización de servicios de tipo profesional, y que su buena gestión exige rediseñar el contrato social con los profesionales y promover la delegación responsable, la rendición de cuentas, la reducción de conflictos de interés, y la cultura cooperativa y de excelencia. La micro-gestión es la clave.

A pesar de los avances puntuales que se han producido en España, no cabe decir que el SNS haya tenido una estrategia decidida en ésta línea. Tres factores han dificultado esta reorientación estratégica y cultural del SNS:

a) La excesiva politización partidaria, partidaria con su sesgo miope y cortoplacista, y su renuencia a llegar a acuerdos de amplia base y largo alcance; esto ha producido un sesgo de intervencionismo de la Macro-gestión sobre todos los asuntos, restando espacio a la Meso-Gestión (gerencias y direcciones

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autonomía real y responsable a la Micro-Gestión.

médicas y de enfermería), y erosionando la posibilidad de otorgar

b) Una cultura de gobierno autocomplaciente y negadora de los problemas, problemas que derivaba todas las tensiones alimentando un escenario expansionista y providencialista; en el contexto de la descentralización a 17 CCAA, esto provoca una tendencia inflacionaria en recursos (competir al alza para evitar diferencias y agravios comparativos); también promueve una extraña pugna de marketing político para mostrar grandes avances tecnológicos, pero no una competencia en resultados para promover la excelencia (los sistemas de información no aportan el marco comparativo necesario, y la información “delicada” se oculta celosamente).

Los

gerentes hospitalarios van perdiendo legitimidad y autoridad por el achique de espacios que produce la macro-gestión politizada, y ante la dificultad de manejar conflictos cuando está altamente penalizado el ruido mediático: esta ausencia de meso-gestión no beneficia a la micro-gestión: produce desgobierno; también inseguridad y discontinuidad de proyectos de cambio, dado que cualquier alternancia política altera la continuidad de los equipos directivos. c) La desconfianza en los profesionales se mantiene, mantiene a pesar de que la profesión médica consolida cambios sociológicos, organizativos y éticos de gran relevancia e interés social, y contra la evidencia de los estudios de organización, que aconseja potenciar la autonomía de los micro-sistemas clínicos. Los responsables políticos e institucionales hace dos décadas (visión socialdemócrata) mantenían una relación adversarial con la profesión médica por el desajuste intrínseco del desempeño profesional con

los

modelos

jerárquicos

administrativos;

hoy,

desde

postmodernidad (visión liberal-conservadora) se reedita e incluso recrudece esta distancia, al propugnarse modelos de control contractual basados en el pago fragmentado por ítems de servicio o sistemas alambicados de algoritmos de productividad variable.

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correctas para una relación que debe estar asentada en la confianza, la

Ni la suspicacia weberiana ni la emulación de mercado son respuestas

ética, y la rendición integrada de resultados en términos de ganancia de salud, seguridad, calidad y satisfacción de los pacientes. Encontrar estos modelos de profesionalismo activo es esencial para garantizar la sostenibilidad de los sistemas públicos de salud y también para superar la

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crisis de la medicina y el queme de los médicos.

Capítulo II

LA NECESIDAD DE UN GRAN ACUERDO POLITICO

La posición desde la que los profesionales piden un Acuerdo político no es la de una defensa a ultranza de soluciones técnicas (por supuesto a un problema técnico) implementadas por técnicos. Entendemos perfectamente la naturaleza política de las reformas sanitaria y precisamente por eso pensamos que se requieren negociaciones inteligentes y productivas en el ámbito político, convencidos, como estamos, de que existen muchos elementos de esa naturaleza en las decisiones que afectan al SNS.

Al mismo tiempo constatamos que entre los grandes partidos españoles no existen diferencias en lo que respecta a los grandes principios que informan la existencia y el funcionamiento de nuestro sistema sanitario. Por otra parte, observamos que entre los países avanzados de la UE, cuyas sociedades son en muchos casos más igualitarias que la nuestra, existe una variedad significativa de modelos de sanidad pública, todos ellos plenamente enmarcados y compatibles con un Estado de bienestar desarrollado. Ello significa que existe un amplio espacio de negociación y acuerdo sin que signifique necesariamente alterar las bases fundamentales del sistema. Este es el tipo de pacto factible que, renunciando a maximalismos con frecuencia electoral o clientelarmente interesados, se puede y debe alcanzar.

En este sentido, los médicos quieren ser protagonistas activos de este Acuerdo que podría revestir la forma de un apoyo explícito a esta propuesta de la OMC y que establezca una serie de iniciativas concretas que permitan mejorar la efectividad y eficiencia en el uso de los recursos sanitarios ofreciendo servicios

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Para ello se requerirá en todo caso máxima independencia en la

de verdadera calidad.

organización y gestión de todas las organizaciones asistenciales, máxima transparencia informativa, un marco financiero definido y estable, sin perjuicio de la necesaria flexibilidad teniendo en cuenta las cambiantes circunstancias externas y un marco de cooperación entre CCAA que permita utilizar los recursos (humanos y materiales) del conjunto del sistema de manera eficiente.

Enfrentados a la confección de un documento que busque el deseado consenso, lo primero en que se piensa es en una serie de actuaciones inmediatas que un grupo de expertos (en este caso, un grupo de médicos) considera que son las adecuadas. Por ejemplo, qué tipo y cuantía de copago debe admitirse, como tiene que ser la carrera profesional, qué incentivos hay que crear o que prestaciones deben y no deben financiarse, incluyendo los medicamentos. Creemos, sin embargo, que no es este el documento que habría que preparar. Pensamos más bien que el acuerdo político debe ser aquel que libere las potencialidades del sistema sanitario y de todos sus partícipes y contribuya a superar las situaciones de bloqueo que todos conocemos y que desde hace muchos años impiden reformas necesarias.

¿Cuáles son esas situaciones? Probablemente algunas se queden en el tintero, pero no es difícil identificar la tendencia al “café para todos” que impide a cualquier nivel, sobre todo en el de los recursos humanos, discriminar a favor de la excelencia en procesos y resultados. De ello sería un ejemplo la tendencia a crear estructuras o dotar servicios con fines electorales o directamente clientelares. Por otra parte, también la dificultad para y la resistencia a valorar objetivamente la eficiencia relativa de instituciones públicas y privadas financiadas públicamente en el logro de resultados de calidad (es obvio que si hay riesgos de calidad/eficiencia en situaciones de provisión privada, también los hay en el caso de la provisión pública y que la objetivación de las distintas

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Por consiguiente, el acuerdo tiene que abordar más bien los instrumentos

situaciones exige un abordaje descargado de prejuicios).

promoviendo, la creación de estructuras estables y muy profesionales que puedan efectivamente identificar los problemas de todo tipo que hoy dificultan el buen funcionamiento del sistema y plantear las soluciones adecuadas, teniendo en cuenta consideraciones políticas, económicas, sociales y, desde luego, manejando criterios técnicos debidamente contrastados. En definitiva, robustecer la institución que es la sanidad pública, haciéndola más “inclusiva” en términos de sociedad civil y, por tanto, más sólida e independiente.

En ese sentido, abogamos para que las estructuras directivas desde el máximo nivel, tanto en el Ministerio como en los departamentos de salud de las CCAA, se ocupen por profesionales de reconocido prestigio. También planteamos que se cree (o se configure algo que ya existe) un órgano independiente encargado de identificar desinversiones y aprobar, en su caso nuevas inversiones/prestaciones Asimismo planteamos la creación de otro organismo igualmente independiente responsable de la evaluación permanente de todas las instituciones sanitarias, sus procesos y resultados ofreciendo con absoluta transparencia los datos pertinentes. Este sería

el modo de superar

debates estériles apoyados en una mezcla de prejuicios y opacidad y que tanto tiempo hacen perder. Los partidos políticos deben comprometerse a establecer los procedimientos necesarios para que este tipo de independencia sea una realidad en el plazo más corto posible.

Todo ello que significa, en último extremo, que en el nivel político quedarían las grandes decisiones que son el QUE servicios se prestan con recursos públicos, el CUANTO –volumen de recursos que se destinan a asistencia sanitaria (conviene no olvidar que hay otras políticas con impacto favorable sobre la salud y que no son sanitarias)- y la garantía del principio de equidad. Como es natural, el nivel político es el facultado para exigir responsabilidades a los niveles

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directivos, pero no para sustituirle en sus actuaciones.

Este Acuerdo permitiría alcanzar un consenso acerca del funcionamiento del SNS, manteniendo al poder político dentro de los límites que le corresponden, permitiendo estabilidad en el desarrollo de unas actividades profesionales independientes, plenamente dirigidas a obtener la máxima eficiencia y calidad, todo dentro de un esquema de transparencia que permita a la sociedad conocer que uso se da a sus impuestos y con qué resultados. Y enfrentando a cada agente o parte del sistema con su responsabilidad a través de un

mecanismo

explícito

rendición

cuentas.

Profesionalmente, no podemos entender y mucho menos aceptar la permanente utilización del tema sanitario como escenario de confrontación partidaria cuando por otro lado todos proclaman las excelencias de modelo de SNS y manifiestan (fuera de escena) un grado de acuerdo considerable en casi todo. Semejantes incoherencias alcanzan niveles patéticos cuando el mismo partido defiende en temas sanitarios posiciones contrarias según esté en el poder o en la oposición o en una u otra Comunidad Autónoma contribuyendo al descrédito y desprestigio de lo político.

La actual situación de emergencia económica obliga a duros, dolorosos, polémicos

y probablemente inevitables ajustes a corto plazo. Admitimos la

existencia de un cierto nivel de pasión en su defensa y en su rechazo, pero habremos de arrinconarla para configurar y defender las reformas estructurales que se proponen y que también vehementemente pedimos sean aceptadas y

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consensuadas de modo explícito y público por las fuerzas políticas concernidas.

Capítulo III

GESTIÓN Y BUEN GOBIERNO DE CENTROS Y SERVICIOS SANITARIOS PÚBLICOS

Una actividad de la envergadura social y económica de la atención sanitaria pública debiera suponer la participación efectiva y corresponsable de ciudadanos y profesionales en orden a conseguir el mejor uso de los servicios sanitarios.

Los profesionales por su parte deben contribuir de forma proactiva a la mejora de la eficiencia y calidad del SNS, implicándose con responsabilidad plena en la organización, funcionamiento y toma de decisiones que afectan a la prestación de los servicios.

Aunque mucho se ha hablado de la participación de los médicos en la gestión del SNS, poco se ha hecho al respecto, más allá de su presencia en comités asesores, receptores de notificación de novedades organizativas y de la ubicación de algunos profesionales en distintas posiciones en la estructura de gestión. Tal clase de participación es además de profesionalmente insatisfactoria, funcionalmente inútil por cuanto no transfiere responsabilidad y riesgo a los médicos. No es esa la aspiración de los profesionales. Por la propia naturaleza del quehacer clínico los médicos han de tener un protagonismo central decisivo en el SNS, expresado en un liderazgo efectivo que ha de concretarse tanto en el nivel estratégico como en la implementación de programas específicos.

Obviamente el correlato de dicho protagonismo en las decisiones implica la asunción de responsabilidades. Responsabilidad, riesgo y rendición de cuentas

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fuerte compromiso con la sociedad y es consciente de que los recursos a su

son elementos que deben acompañar al protagonismo. La profesión tiene un

disposición no son ilimitados. Pero también sabe cómo dar el mejor uso posible esos recursos.

En modo alguno se pretende desplazar y exonerar a los poderes públicos de sus obligadas y legítimas responsabilidades ante la ciudadanía en materia sanitaria, mas bien al contrario se les exigirá que realmente gobiernen y piloten esta nave tan a menudo a la deriva que resulta ser el SNS para lo que resulta ser imprescindible la implicación corresponsable y efectiva de los profesionales en diferentes niveles y para distintas tareas.

Las líneas de trabajo y cambio que se proponen se detallan a continuación

III. 1 Órganos de representación y participación colegiada

Para ejecutar esta deseada participación de los profesionales en el SNS, nos permitimos formular las siguientes propuestas, siempre sometidas al oportuno debate y valoración. a) Macro-participación para el conjunto del Sistema Nacional de Salud, en el ámbito del Estado. Para su viabilidad, esta macro-participación exige, al menos, tres requisitos esenciales: la objetividad e independencia, la alta cualificación de los partícipes y la capacidad real de decisión. En ese sentido, parece oportuno que se instrumente en el ámbito del Parlamento español, como una comisión dependiente de la representación popular. En aras a la eficacia se debe determinar, también, el alcance y contenido de las materias objeto de abordaje; la necesaria formulación de consulta preceptiva previa, no vinculante, para la adopción de las diferentes decisiones; y los integrantes de la comisión, que deberán proponer corporaciones

organismos

profesionales, las sociedades científicas,

como

los

colegios

las universidades, o la

tecnoestructura del Ministerio de Sanidad o del Gobierno de la Nación.

entes,

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distintos

b) Una participación más reducida a nivel territorial, con especial protagonismo de los servicios autonómicos de salud, que es donde se adoptan las medidas de gestión que afectan al sistema y tienen una repercusión inmediata. Este nivel participativo debe tener su sede en los correspondientes parlamentos regionales. Su elección y control deben seguir las mismas pautas que las señaladas en el apartado anterior.

c) Por último, resulta

oportuno habilitar un sistema de participación y

decisión en cada área de gestión integrada, o en modelos similares. Las actuales juntas facultativas. técnico-asistenciales, comisiones mixtas, u otros órganos de participación equivalentes, no funcionan y, si lo hacen, es mediante reuniones de limitado alcance o de escasa o nula eficacia. Para la elección de sus integrantes, de la mayor cualificación y objetividad, debe optarse por un sistema ágil y nada farragoso.

Sus competencias y

funciones deben ser las ya señaladas en los casos anteriores. Siempre preceptivas, aunque no vinculantes, en aquellas materias y decisiones de relieve, incluso las que afecten a las potestades organizativas de las Administraciones.

III. 2

Profesionalización de directivos

Mayor profesionalización y menor injerencia política, en los puestos de gestión de los centros sanitarios. Semejante obviedad debe ser señalada y subrayada una vez más por cuanto, aunque algo se ha mejorado, es preciso insistir en ello para asegurar una mayor continuidad y estabilidad de las

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organizaciones.

III. 3 Reformas en el ámbito organizativo y retributivo

Se debe romper con la clásica estructura de nivel asistencial (atención primaria por un lado y atención especializada por otro), y promover la integración real de proveedores que atienden a una población. Eso exigiría que el conjunto de proveedores que atienden a esa población compartan un presupuesto, ajustado al tipo de población que atienden, y orientado a mantener a la población sana.

En el caso particular de la Atención Primaria, co-protagonista de la necesaria reorientación asistencial hacia los cuidados de larga duración; los equipos de atención primaria deben asumir una capacidad real de autoorganización, así como manejar instrumentos para actuar como agentes de sus pacientes ante la red sanitaria y socio-sanitaria.

Se propone también ensayar un cambio de modelo contractual que se aleje de la actual integración vertical –empleados públicos cuyo salario depende prácticamente de su statu quo, que trabajan en centros de titularidad pública-, y adopte el formato de agrupaciones de profesionales con las que el financiador público contrata servicios cualificados tras evaluación. Se trataría de fomentar modelos asimilables al trabajo por cuenta propia. propia

En la mayoría de países de nuestro entorno la atención primaria no está integrada en la función pública, sino que se vincula por un sistema contractual; el financiador público desarrolla una regulación amplia, pero se basa en la autogestión de los centros de salud por parte de sus profesionales. Los modelos de financiación son diversos, pero son muy comunes el componente capitativo y la existencia de incentivos en función del cumplimiento de objetivos y la generación de ahorros. La iniciativa pionera de las Entidades de Base Asociativa

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resultados positivos en el marco organizativo del SNS.

en Cataluña demuestra que estas experiencias pueden ser aplicables y ofrecer

La remuneración debe tender a favorecer la longitudinalidad, debe aumentar el peso del componente capitativo y de los incentivos, cuya misión principal es alinear clínica y gestión, Se debe garantizar una estabilidad en los incentivos, para evitar que sean la primera partida a suprimir en épocas contractivas de la economía.

Por otra parte, presupuestar la atención sanitaria a una población (financiación financiación capitativa capitativa) tiva en lugar de seguir presupuestando por los servicios sanitarios de distintos proveedores poco coordinados, favorecería la integración asistencial ayudando a evitar entre otras duplicidades, retención de pacientes y la iatrogenia de exceso de tecnología. Obviamente, estos modelos capitativos deberían incorporar tanto ajustes de riesgo (necesidades de la población), como modulaciones por tendencias históricas de frecuentación y gasto.

Permeabilizar el trasiego de profesionales entre especialidades, reduciendo los silos de producción actuales: cada especialista se forma y trata a los pacientes desde el “órgano” del cuerpo en el que está especializado, olvidando que trata pacientes complejos. Ligado al anterior, y considerando la tipología de pacientes más prevalentes en nuestras sociedades es necesario reorganizar los servicios en función de la trayectoria clínica esperable para cada tipo de paciente: un paciente crónico, verá a lo largo de su vida numerosos especialistas. El objetivo sería evitar que este paciente disponga de un juicio clínico independiente por cada médico que lo ve, a veces contradictorio, y proporcionarle un plan de cuidados coordinado.

Las medidas organizativas van de la mano con la necesidad de evaluar y retribuir en función de desempeño (esfuerzo y resultados), tanto a los profesionales, como a los centros sanitarios que proveen los servicios. Debería

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necesariamente implican añadir más salud.

limitarse el pago por acto allí donde proporcionar más servicios, no

Es necesario dejar atrás comportamientos paternalistas y dar paso a toma de decisiones compartidas. compartidas Informar de los mejores cursos de acción en los múltiples ejemplos de toma de decisiones compartidas, que logran disminuir el porcentaje de usuarios pasivos, de pacientes indecisos, que con información correcta tienden a usar tecnologías menos invasivas y a tomar decisiones de mayor calidad. Se evita también el exceso de mortalidad que provoca la falta o baja alfabetización en salud. El paciente es quien debe saber cómo conservar su salud, el profesional conoce los medios diagnósticos y terapéuticos para intentar recuperarla. Tener en cuenta los valores, preferencias del usuario del sistema sanitario y el balance riesgo beneficio de las opciones que ofrece el profesional produce decisiones más acertadas. Paciente experto, aulas de pacientes y universidades de pacientes son otros ejemplos de cómo disminuir demanda asistencial mejorando a su vez el control de la enfermedad y la seguridad clínica. Con el empoderamiento individual se trata de que el paciente tenga mayor vigilancia sobre las decisiones y acciones que afectan a su salud personal. Con el empoderamiento colectivocolectivo-comunitario, comunitario actuaciones colectivas que produzcan cambios en los determinantes de salud mejorando el entorno donde vive el usuario, un entorno promotor de salud. Existe demasiada dependencia del sistema sanitario como determinante de salud. Si los determinantes sociales son los mayores determinantes de la salud, así deben ser las soluciones.

III. 4

Práctica Práctica médica apropiada, Evaluación de Tecnologías y Cartera de

Servicios

El reto del profesionalismo médico sigue siendo aportar valor a la salud de individuos y poblaciones. Es preciso desterrar de la práctica las intervenciones

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Es imperativo un cambio en el paradigma ético. ético Del “para mi paciente lo

sanitarias que no añaden valor y pueden producir daño.

mejor no importa su coste” al “dados recursos finitos, muchos pacientes no podrán recibir los mejores cuidados si en mis decisiones se produce desperdicio de recursos”. Este cambio de paradigma, tiene una derivada directa en cuanto al principio primum non nocere nocere. La aplicación de técnicas sin valor o de dudoso balance entre beneficios y riesgos, ponen a riesgo de daño innecesario a los pacientes o poblaciones que las reciben.

1. Medicina de dudoso valor.

Es imprescindible ser conscientes de la magnitud del fenómeno.. Entre el 30% y el 50% de las decisiones médicas no añaden valor a la salud los pacientes o poblaciones que son afectadas; por consiguiente, entre un 30% y 50%, los costes asociados son equivalentes a desperdicio de recursos. En España existen numerosas pruebas de la producción de cuidados de escaso valor; algunos botones de muestra: 55% de faringoamigdalitis inadecuadamente tratadas, 53% de mujeres con tratamiento anti-osteoporosis mal indicado, 8% de ingresos y 10 por mil de consultas derivaron en algún evento adverso, 12% de ingresos relacionados

con

problemas

medicación,

hospitalizaciones

potencialmente evitables en enfermos crónicos, una diferencia injustificada en gasto hospitalario estandarizado cápita de 2 veces entre áreas sanitarias, 1 caso tromboembolismo o trombosis por cada 500 intervenciones quirúrgicos atribuible a algún déficit en los cuidados, diferencias de hasta 4 veces en el acceso a cirugía conservadora

de mama, incremento en el gasto cápita que no se

convierte en equivalentes de salud, decenas de miles de casos de cirugía potencialmente evitables por existir alternativas terapéuticas más efectivas, etc. Una mirada a los estudios de variabilidad de práctica disponibles en www.atlasvpm.org puede arrojar luz. Reconocer que a menudo las decisiones médicas no añaden nada a la salud de los pacientes y las poblaciones, es el

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Esta situación obedece a diversas causas, como:

primer paso.

a) Cuidados innecesarios: incluyen tratamientos realizados sobre pacientes que no los necesitan según la evidencia, o pacientes con serias dudas sobre el balance entre beneficios y riesgos. Incluye, utilización innecesaria de las tecnologías de más alto coste. La mal llamada “medicina defensiva” estará también en esta categoría.

b) Servicios provistos de manera inapropiada e ineficiente: Especialmente importante en nuestro sistema la fragmentación de cuidados (incluso dentro del propio centro asistencial), el uso inapropiado de los recursos (estancias prolongadas artificialmente, visitas médicas de seguimiento sin valor, etc.) y consecuencias del error médico o de las complicaciones atribuibles a cuidados deficientes.

c) Oportunidades de prevención desaprovechadas: En el terreno de la prevención: abandono del consejo médico y la promoción de la salud como parte del instrumental médico necesario, hospitalizaciones evitables en pacientes crónicos, etc.

d) Uso indebido de recursos: ligado a conflictos de interés con otros agentes del sistema, en particular, pero no sólo, la industria.

2. La experiencia internacional.

Otros lo han hecho. Las agrupaciones profesionales de países de referencia, ya han iniciado el camino. Dos ejemplos de interés en Estados Unidos:

Choosing Wisely compendio de diversas iniciativas sobre

profesionalismo médico, con más de una década de aportaciones,

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médicas (http://www.choosingwisely.org); 2) The Institutes of Medicine (IOM)

identificado un listado de prácticas innecesarias que afectan a 9 especialidades

ha considerado un imperativo elaborar una estrategia para disminuir costes sanitarios, manteniendo o mejorando los resultados de salud. Para ello consideran prioritario, reducir las hospitalizaciones evitables, evitar readmisiones y

reducir

los

cuidados

innecesarios.

(http://www.nap.edu/catalog.php?record_id=12750)

3. Una Agenda de actuaciones

Es responsabilidad de los médicos liderar las reformas precisas, en un debate leal con las autoridades sanitarias. La agenda de acciones que buscan incrementar el valor es variada; una parte muy importante de la misma está relacionada con hacer mejor Medicina Medicina: edicina

- Utilizando la mejor evidencia disponible - Disminuyendo los cuidados innecesarios - Mitigando los errores y las consecuencias ominosas de prácticas subestándar - Eligiendo los recursos más eficientes para proveer los cuidados - Mejorando la continuidad de cuidados - Facilitando que, ante incertidumbre, el paciente comparta la decisión - Cultivando la transparencia en los resultados y los recursos utilizados - Reconociendo el fraude y persiguiéndolo activamente

También es responsabilidad de los médicos exigir lealmente una administración más comprometida con el objetivo de añadir valor. valor Para ello será preciso:

- Construir sistemas de información que permitan disponer de la mejor evidencia

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retroalimentan con la experiencia diarias de médicos y servicios;

para tomar decisiones en situación de incertidumbre; sistemas que se

- Financiar selectivamente aquello (tecnologías, servicios, etc.) que añade valor; para ello se deberá conferir un papel real, relevante y decisivo a los dictámenes e informes de las agencias de evaluación de tecnologías en España, actualmente organizadas en una sola red. Se trata de llevar a la vida real lo que formalmente está recogido en el marco legal (Ley de cohesión y Calidad del SNS y otras normas) usando de verdad

el producto de la información y conocimiento

independientes y fiables para la toma de decisiones político-sanitarias tal como se ha hecho en otros países avanzados (el NICE es un magnífico ejemplo). Se debería además introducir el uso tutelado para determinadas innovaciones tecnológicas, de manera que pudiera compatibilizarse el estímulo a la innovación con el riesgo de consumo excesivo no compensado por el incremento en

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eficiencia que asume el pagador público.

Capítulo IV

LA PROFESIÓN MÉDICA. EL MÉDICO QUE NECESITAMOS

IV.1

Responsabilidad, compromiso y valores: la crisis de la fragmentación y

tecnificación deshumanizada de la práctica médica

ejercicio de la profesión médica acorde con los tradicionales

principios hipocráticos

y con los que conforman el denominado “nuevo

profesionalismo” supone compromiso con la honestidad en la utilización del conocimiento y en la optimización de los recursos, con la compasión como guía de acción frente al sufrimiento, con la mejora permanente en el desempeño profesional para garantizar la mejor asistencia posible al ciudadano y la colaboración con todos los profesionales e instituciones sanitarias en aras de la mejora de salud y el bienestar de la población.

La prestación de servicios por parte del profesional médico no es gratuita. Genera costes de manera directa e indirecta que, dependiendo del ámbito y modelo sanitario, debe afrontar el paciente, una compañía de seguros o el Estado. En este contexto en el que la eficiencia se entiende como la manera de conseguir los resultados perseguidos al menor coste posible, no podemos eludir la implicación profesional del médico. La responsabilidad en el ejercicio de la medicina moderna no puede considerarse como un asunto aislado dentro de la relación médico-paciente, sino que tiene una dimensión social que trasciende a la misma siendo esta dimensión uno de los elementos más novedosos del nuevo profesionalismo médico

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exige comprender la génesis de un modo de ejercer la profesión en el SNS de la

El ejercicio riguroso del nuevo profesionalismo es tarea difícil y su logro

España de hoy que resulta ser el fruto de un triple y venturoso desarrollo científico y social:

1. Un

espectacular

crecimiento

las

posibilidades

diagnosticas

terapéuticas fruto del desarrollo científico y tecnológico de los últimos treinta años. 2. La incorporación efectiva de dichas posibilidades a un dispositivo asistencial universal y público a través de una mismo

de recursos materiales y humanos

creciente asignación al junto a modificaciones

organizativas acordes con los imperativos tecnológicos. 3. La consolidación y extensión de un modelo de formación de especialistas (MIR)

de alto contenido técnico que además ha condicionado en gran

medida la orientación de la formación pregraduada.

Aunque todos, ciudadanos y profesionales, calificamos como básicamente exitoso y positivo el resultado alcanzado no debemos ignorar la aparición de algún efecto colateral indeseado cuya existencia pone de manifiesto carencias graves en el cumplimiento de los compromisos del nuevo (y viejo) profesionalismo además de amenazar seriamente la legitimidad y sostenibilidad del propio sistema.

Los mismos tres vectores de desarrollo mencionados han determinado la emergencia del fenómeno de la hiperespecialización

y su corolario, la

fragmentación del proceso asistencial. La híper-especialización medicina y su

divide

ejercicio en porciones menores sin aportar mecanismos de

coordinación e integración, lo que a su vez provoca la búsqueda estimulada de pacientes que se puedan beneficiar de ese conocimiento hiperespecializado. Ambas consecuencias aumentan las necesidades de recursos humanos y técnicos,

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añadiendo el riesgo de descoordinación de terapias y terapeutas.

más médicos y medios diferenciados para atender a un único paciente o proceso

En paralelo con el fenómeno de la fragmentación, ha discurrido un modo de ejercicio profesional centrado casi exclusivamente en la dimensión orgánicobiológica del binomio salud-enfermedad, más empeñado en identificar y corregir desviaciones de la “normalidad” biológica que en lograr el bienestar mas razonablemente alcanzable de cada paciente en su circunstancia personal y social específica

Tales modos de ejercicio de la medicina no responden con suficiencia en calidad y condiciones al modelo de profesional que defiende la profesión médica, ni tampoco a los compromisos fijados por el contrato social tácito o expreso que mantiene ante los ciudadanos. El paciente y su enfermedad son únicos y único y personalizado debería ser el proceso asistencial con el que se le atiende. Sin embargo

la amplia disponibilidad de

terapéuticos y especialistas unida a deficiencias

métodos diagnóstico-

formativas y organizativas

ocasionan con gran frecuencia una asistencia fragmentada e inapropiada. El paciente y su proceso asistencial se mueven a lo largo de una cadena interdisciplinar (con eslabones a menudo innecesarios) en la cual, la debida dirección unitaria y coordinación entre los distintos especialistas y niveles asistenciales son palmariamente

inexistentes. Si este fenómeno fue siempre

rechazable, hoy resulta simplemente inaceptable al constituir el paciente mayor, crónico y pluripatológico, el usuario hegemónico del SNS más vulnerable que nadie a las consecuencias de

funcionamiento asistencial pensado para

episodios agudos y no para largas vidas con padecimientos crónicos.

La extensión y crecimiento inercial del modelo vigente (mayor fragmentación, mas consultas y derivaciones, mas especialistas, más tecnología) es además de económicamente inviable, médicamente indeseable. Se impone pues el fomento decidido de un cierto neogeneralismo humanista e integrador

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avanzados. Ello implica actuaciones estructurales y organizativas ya señaladas en

tal como se está propiciando (o conservando) en países con sistemas sanitarios

el capítulo anterior (Capitulo III) pero sobre todo un cambio cultural en el seno de la profesión médica que conforme el médico que necesitamos modificando profundamente el estilo de práctica profesional

IV. 2 La formación del médico que la sociedad necesita

Un ajuste de roles y aptitudes profesionales como el que demanda el cambio cultural propuesto supone en primer lugar modificar y/o reorientar la formación médica, tanto en el nivel de grado/licenciatura como en el de la formación postgraduada (MIR) y sobre todo, por la necesaria inmediatez de efectos, en la continuada.

Ello implica además de la adquisición y actualización de conocimientos, habilidades y competencias necesarias (que por cierto van más allá de los elementos tecnobiológicos), la internalización y renovación de los valores y creencias que conforman la identidad profesional. Es preciso integrar la dimensión de economía de la salud por parte de los profesionales sanitarios. Urge interiorizar que los recursos son escasos y la demanda (en un país como el nuestro donde el coste en el momento de recibir asistencia es cero) ilimitada, que cuanto mayor es el progreso médico, mayor es el coste de obtener mejoras adicionales, que si los recursos son escasos, estamos obligados a buscar la mejor forma de gastarlos, y que existe un coste de oportunidad en las decisiones que tomamos día a día en condiciones de incertidumbre. Y todo esto sin dejar de tener presente que ante todo tenemos un SNS donde prima la equidad.

Por otro lado, el desarrollo académico de la bioética ha prestado escasa atención a la formación del los futuros profesionales en el compromiso, la responsabilidad y la perspectiva humanista del concepto salud-enfermedad. La

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toma de decisiones problemáticas en la práctica clínica y en áreas de debate

ética de las profesiones sanitarias en las últimas décadas se ha focalizado en la

(cuestiones éticas al comienzo y al final de la vida). El respeto a la autonomía del paciente se ha inculcado a menudo desde una perspectiva legalista (documentos de consentimiento informado y de voluntades anticipadas) de tal modo que la norma está venciendo al espíritu de la ley. En la práctica de la docencia de las Facultades de Medicina se ha instaurado una dicotomía entre técnica y ética, como si fueran orbitas separadas

que pueden encontrarse ocasionalmente

cuando hay conflictos olvidando que “técnica” en medicina es sobre todo práctica clínica, concepto que necesariamente incorpora dimensiones éticas

No es este el documento en el que se deban pormenorizar propuestas de contenidos específicos a incluir o modificar en los tres niveles de formación mencionados pero si indicar que tales acciones exigen reflexión y acción sincronizada de las autoridades de Sanidad y Educación y las organizaciones profesionales, con acciones en diferentes ámbitos prestando especial atención a la siempre olvidada formación continuada. En todo caso la inculcación decidida del rechazo de la práctica clínica inapropiada (inútil, innecesaria, insegura, inclemente o insensata) y las propuestas formativas acordes con tal logro habrán de presidir la orientación de los cambios dirigidos a formar y mantener ese médico del futuro que tan acertadamente ha dibujado con diez rasgos Fundación

para

Educación

Médica

2009

(http://blogderozman.wordpress.com/page/2).

Es oportuno señalar aquí que al menos en el ámbito de la formación postgraduada se ha iniciado el camino del cambio en la dirección correcta con el inminente Decreto de Troncalidad de especialidades médicas que apuesta por un médico con una formación troncal común integradora que lo hace mas polivalente y versátil.

Igualmente oportuna y necesaria resulta una

redefinición de roles y

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espacio que debe, liberando al médico de la realización de tareas que consumen

responsabilidades profesionales en la que la enfermería y otro personal ocupe el

un valiosísimo tiempo que hoy no puede aplicar a aquello que le es propio e intransferible.

IV. 3 Necesidades de médicos

Esbozadas las líneas generales relativas al tipo de médico que necesitamos convendrá hacer un ejercicio estimativo acerca de necesidades de médicos y especialistas.

Es tarea compleja ya que además de las consideraciones relativas a la demografía médica

que hasta ahora se han tenido en cuenta (casi

exclusivamente) se deberá contar con al menos dos escenarios futuros Hemos de imaginar un nuevo escenario en el que el médico generalista (atención primaria, internista, geriatra) ocupe un mayor espacio y capacidad resolutiva junto a un especialista dotado de mayor versatilidad sin olvidar que nuevos avances

tecnológicos demandarán en el otro

extremo del proceso asistencial profesionales superespecializados con capacitación específica para tareas complejas muy concretas Asimismo la señalada redefinición de roles profesionales condicionará enormemente la estimación de necesidades de médicos

De no hacerlo así nuevas estimaciones basadas en la suposición de un

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escenario como el actual volverán a ser erróneas.

PROPUESTAS

1. Necesidad de un Acuerdo político

Los médicos consideramos que se necesita urgentemente un Acuerdo político al máximo nivel que facilite la imprescindible y, desde hace años, postergada, reforma del SNS, de manera que se garantice su solvencia y no sólo se evite la vulnerabilidad con que se enfrenta en la actualidad a la profunda crisis económica en la que el país se encuentra sumido, sino que habilite a la sanidad pública como una institución robusta e independiente, capaz de ofrecer servicios de la máxima calidad y eficiencia de cara al futuro. Para ello:

a) Este Acuerdo debe promover un mayor protagonismo profesional en los niveles estratégicos de decisión,

lo que creemos impedirá que se

instrumentalice la gestión por intereses partidistas y se malgasten energías en enfrentamientos estériles, que sólo sirven para confundir a la población, en los que se lanzan propuestas no avaladas por evidencia alguna que justifique su idoneidad. b) Así mismo, debe servir para liberar las enormes potencialidades del Sistema y sus agentes, ahora encorsetadas en un entramado burocrático muy desincentivador, y ha de contribuir a facilitar la creación de estructuras de gobierno estables y profesionales, en las que exista una clara identificación de responsabilidades acompañada de mecanismos de evaluación y control totalmente transparentes.

Consideramos así mismo que si la frustrante incapacidad de alcanzar acuerdos se mantuviera, los médicos primaríamos la colaboración con las formaciones políticas que suscriban los planteamientos expresados en este

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documento.

2. Establecer Establecer políticas que garanticen una financiación sanitaria estable y equilibrada para los distintos servicios de salud de las CCAA:

a) No parece fácil (ni realista) aceptar el retroceso de la financiación sanitaria pública al 5,1% del PIB en 2015 (como establece el actual Programa de Estabilidad del Reino de España 2012-2015). Sin que quepa hablar de un porcentaje correcto, parece que las aspiraciones de una sanidad de calidad para todos los españoles no es compatible si nos situamos muy por debajo del 6,5% del PIB: PIB la media de la OCDE era de 6,9 en 2009 (Health at a Glance, OECD, 2011). b) Para garantizar una financiación territorial más justa, debería promoverse una modificación de la financiación autonómica, autonómica que determinara y delimitara el gasto sanitario público y lo protegiera con una estimación de un “per cápita”, ajustado por necesidad, recalculado periódicamente para cambios demográficos, y con un fondo de compensación o garantía asistencial para la atención prestada a residentes de otras CCAA. La tecnología disponible ayuda a gestionar sistemas de compensación, y éstos evitan tentaciones de insolidaridad o limitación del esfuerzo asistencial. Finalmente, se precisaría mantener y ampliar un fondo de cohesión para nivelar las oportunidades de salud de la población y para incentivar las inversiones que respondan a criterios técnicos de necesidad.

3. Promover el Buen Gobierno en el SNS, a través de medidas legales y técnicas que aborden los problemas estructurales.

a) Dotar al SNS de un marco legal claro y actualizado, actualizado refundiendo las leyes

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ciudadanía sanitaria, Sistema Nacional de Salud, y sus órganos de

y normas anteriores, y estableciendo en positivo el concepto de

gobierno y gestión.

b) Promover en paralelo y para las funciones técnicas de colaboración de los Servicios Regionales de Salud de las CCAA, una estructura agencial con bajo nivel de politización, alto nivel de transparencia, que combine centralidad estratégica y técnica, con estructuración en base a redes territoriales y que tenga una clara vocación de articular los instrumentos de gestión de recursos, de personas, de conocimiento y de información, que constituyen la plataforma de acción compartida del SNS.

c) De igual manera habrá que poner en marcha, utilizando las estructuras y capacidades existentes, una institución profesional e independiente que contribuya a evitar intervenciones asistenciales que no aporten valor al paciente y soporte la actividad de los profesionales con información objetiva, actualizada y debidamente contrastada.

4. Buen Buen Gobierno y Buena Gestión en Centros y Servicios sanitarios públicos.

a) Avanzar en la creación de órganos colegiados de gobierno y en la profesionalización de la gestión: gestión el “Decálogo para el Buen Gobierno de

los centros sanitarios y la profesionalización de la dirección“, documento de 2005 que promovió la OMC junto con SESPAS y SEDISA, sigue siendo plenamente vigente, y, salvo algunas iniciativas aún no consolidadas (País Vasco), continúan siendo propuestas escasamente atendidas por los responsables políticos e institucionales.

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https://www.cgcom.es/sites/default/files/05_03_16_buen_gobierno_0.pdf

b) Promover un rediseño de los servicios públicos de salud: que facilite la acción integrada entre niveles asistenciales; que permita reconducir la excesiva fragmentación asistencial; que restaure el enfoque integral y longitudinal a la persona enferma; que potencie decididamente a la atención primaria y su papel de gestor clínico de red; que ordene el territorio para racionalizar tanto los servicios de proximidad como los de alta especialización; que ponga en marcha estrategias para pacientes crónicos, pluripatológicos y terminales;

y que vaya aportando

instrumentos de gestión a los centros y servicios, para que puedan promoverse modelos efectivos de gestión clínica.

5. Profesionalismo y creación de capital clínico, ético y gestor en las profesiones sanitarias.

a) Un contrato social renovado con las profesiones sanitarias: sanitarias porque es la cultura, no la economía, la que garantizará la sostenibilidad de los sistemas públicos de salud. Para ello son necesarios múltiples cambios, en la formación, en el desarrollo profesional, y en la gestión del factor humano profesional. Este es un reto para el cual el SNS debería abrir un espacio de reflexión claro y vinculante. Las nuevas generaciones de médicos y especialistas deberían participar desde el inicio en el debate sobre los retos éticos y organizativos que hoy plantea trabajar en la moderna medicina y en los sistemas sanitarios público. b) Un pacto para gestionar la crisis sin descapitalizar la medicina: medicina formar a un facultativo es muy caro y consume mucho tiempo; la disminución de la sanidad pública por recortes en contrataciones, puede dejar a varias cohortes de médicos y enfermeras fuera del empleo durante varios años,

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Los médicos proponemos una reflexión conjunta con las autoridades

mientras que la edad media de las plantillas de los centros aumenta.

sanitarias, cabría contemplar un compromiso: a cambio de no reducir en el empleo joven de médicos, médicos promover activamente el ahorro en el gasto sanitario, incluidas reducciones razonables y temporales de la masa salarial. Para ello se precisaría avanzar en la agenda del Buen Gobierno, la autonomía responsable de la gestión, y la restauración de la confianza entre las partes, que ha quedado muy erosionada con la compulsión de acciones unilaterales de recorte.

Han redactado este documento: documento:

Ignacio Burgos Enrique Castellón José Conde Olasagasti Ricard Gutiérrez Martí Francisco Hernansanz

Julio Mayol José Ramón Repullo Luciano Vidan

Enrique Bernal

Médico de AP, Cátedra de Profesionalismo y Ética Clínica de la Universidad de Zaragoza. Unidad de Investigación en Políticas y Servicios de SaludARiHSP. Centro de Investigación Biomédica de Aragón. Zaragoza. Médico de AP en Ávila. Vicepresidente del Colegio de Médicos de A Coruña. Jefe del Servicio de Nefrología. Hospital Virgen de la Salud. Toledo Vicepresidente del Consejo General de Colegios Oficiales de Médicos. Subdirector de la Cátedra de Medicina de Familia y Economía de la Salud. Universitat Pompeu Fabra. Barcelona. Jefe Sección Cirugía Digestiva del Hospital Clínico San Carlos. Madrid Jefe Departamento de Planificación y Economía de la Salud. Escuela Nacional de Sanidad. Madrid. Presidente del Colegio Oficial Médicos de A Coruña.

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Rogelio Altisent

Foro de la Profesión Médica de España

EL FORO DE LA PROFESIÓN MÉDICA EXIGE LA SOLUCIÓN INMEDIATA A LA SITUACIÓN ACTUAL DE LA SANIDAD DE LA COMUNIDAD DE MADRID • En su reunión de hoy, el Foro de la Profesión Médica también ha ratificado la propuesta de la Organización Médica Colegial relativa a la convocatoria consensuada de una Manifestación en Madrid, prevista para el próximo 23 de febrero • Además, se ha acogido otra propuesta por parte de la Confederación Estatal de Sindicatos Médicos (CESM), consistente en promover movilizaciones por toda España

El Foro de la Profesión Médica es consciente de la grave crisis económicofinanciera que atraviesa nuestro país. Sin embargo, considera que las medidas de ajustes presupuestarios que están afectando a la Sanidad madrileña no justifican, en ningún caso, las formas que el Gobierno de la Comunidad de Madrid (CAM) ha empleado para plantear dichas medidas que el Foro considera absolutamente desproporcionadas, que ponen en riesgo la calidad de los servicios sanitarios, y que se implementan sin la participación de los profesionales. El Foro de la Profesión Médica considera que la respuesta que todos los profesionales han dado a las medidas planteadas por el Gobierno de la CAM ha sido absolutamente coherente y adecuada. Respuesta a la que se han sumado muchos ciudadanos y en la que destaca el alto grado de compromiso con la sociedad y con la calidad de la asistencia sanitaria. Es por ello que ante la grave situación planteada en estos momentos, el Foro de la Profesión Médica ha acordado en su reunión de hoy, 13 de diciembre, celebrada en la sede de la OMC, instar a todas las partes a que se sienten a dialogar y a que se intente llegar a un acuerdo que dé solución inmediata a esta problemática. El Foro de la Profesión Médica se ofrece, asimismo, como mediador entre las partes para intentar que este acuerdo o solución inmediata se adopte a la mayor brevedad.

OMC - FACME - CESM - CNDFM - CNECS - CEEM

Foro de la Profesión Médica de España

CONVOCATORIA DE MANIFESTACIÓN En su reunión de hoy, el Foro de la Profesión Médica también ha ratificado la propuesta de la Organización Médica Colegial (OMC), acordada en Asamblea Extraordinaria y Urgente del pasado 17 de noviembre, relativa a la convocatoria consensuada de una Manifestación en Madrid, como signo de expresión de la unidad del colectivo médico ante la actual situación del Sistema Nacional de Salud. Dicha acción, prevista para el próximo sábado 23 de febrero de 2013, tiene como finalidad, por un lado, la defensa a ultranza del SNS y, por otro, el rechazo unánime a las medidas indiscriminadas que afecten a la calidad de la asistencia y a la buena praxis tanto a nivel del Estado como de las Comunidades Autónomas.

MOVILIZACIONES POR TODA ESPAÑA En la misma sesión de hoy, se ha acogido otra propuesta por parte de la Confederación Estatal de Sindicatos Médicos (CESM), que ha sido valorada positivamente por parte del Foro de la Profesión Médica, consistente en promover movilizaciones por toda España, que sean aprobadas en el Comité Ejecutivo de CESM, previsto para el 9 de enero, y en la Plataforma de Unidad de Acción Médica, constituida por la OMC, FACME y CESM, que se reunirá el próximo 8 de enero, y que contará con la presencia, a su vez, de los estudiantes de Medicina, representados por su Consejo Estatal (CEEM).

Para más información contactar con el portavoz del Foro de la Profesión Médica: -Dr. Francisco Miralles (CESM) Telf: 610 280 441

OMC - FACME - CESM - CNDFM - CNECS - CEEM

CONSEJO GENERAL DE COLEGIOS OFICIALES DE MÉDICOS

La OMC presenta a Núñez Feijoo un documento de propuestas de reforma sanitaria Es un documento “crítico”, con propuestas reales y compromiso de los profesionales para la sostenibilidad del SNS 5 propuestas: acuerdo político, financiación estable, Buen Gobierno en el SNS, buena gestión en centros y servicios y un contrato social renovado con los sanitarios Los médicos se comprometen a promover el ahorro del gasto a cambio de no reducir el empleo de jóvenes La OMC considera una oportunidad contar con la interlocución de un Gobierno sensible como el de la Xunta La Organización Médica Colegial (OMC) ha presentado hoy al Presidente de la Xunta de Galicia, Alberto Núñez Feijoo, un documento de propuestas de reforma sanitaria para una acción inmediata que garanticen la sostenibilidad del Sistema Nacional de Salud. El documento titulado “Profesión Médica y Reforma Sanitaria” fue entregado hoy a Alberto Núñez Feijoo por el presidente de la OMC, Juan José Rodríguez Sendín, en un encuentro celebrado en la Xunta de Galicia, en el que estuvieron presentes también la Conselleira de Sanidad, Rocío Mosquera, y los presidentes de los colegios médicos de A Coruña, Luciano Vidan y Ourense, Pedro Trillo.

CONSEJO GENERAL DE COLEGIOS OFICIALES DE MÉDICOS Este documento, que ha sido elaborado por diez profesionales, la mayor parte de los cuales no ostenta representación institucional alguna y muchos de ellos tienen actividad clínica asistencial, responde a una petición del Presidente de la Xunta de Galicia al presidente de la OMC para conocer el punto de vista de la profesión médica en relación a las tensiones por las que está atravesando la sanidad pública en España. Los 10 profesionales que, durante dos meses, han elaborado este documento son: Rogelio Altisent, médico de AP, director de la Cátedra de Profesionalismo y Ética Clínica de la Universidad de Zaragoza; Enrique Bernal, Unidad de Investigación en Políticas y Servicios de SaludARiHSP. Centro de Investigación Biomédica de Aragón. Zaragoza; Ignacio Burgos, médico de AP en Ávila; Enrique Castellón, vicepresidente del Colegio de Médicos de A Coruña; José Conde Olasagasti, Jefe del Servicio de Nefrología. Hospital Virgen de la Salud. Toledo; Ricard Gutiérrez Martí, vicepresidente del Consejo General de Colegios Oficiales de Médicos; Francisco Hernansanz, médico de AP, subdirector de la Cátedra de Medicina de Familia y Economía de la Salud. Universitat Pompeu Fabra. Barcelona; Julio Mayol, Jefe de Sección de Cirugía Digestiva del Hospital Clínico San Carlos. Madrid; José Ramón Repullo, jefe Departamento de Planificación y Economía de la Salud. Escuela Nacional de Sanidad. Madrid, y Luciano Vidan, presidente del Colegio Oficial Médicos de A Coruña. El documento de la OMC considera que “la respuesta sostenible y eficiente a la crisis financiera en la sanidad, exige cambios estructurales y de estrategias” pero expone que “los recortes lineales bloquean estos cambios e imponen reducciones que no sólo afectan a lo prescindible

CONSEJO GENERAL DE COLEGIOS OFICIALES DE MÉDICOS si lo hubiera, sino que también a lo imprescindible para mantener la calidad de los servicios sanitarios”. Considera que “la única forma de hacer economías selectivas que promuevan la sostenibilidad interna del Sistema Nacional de Salud es revitalizando la alianza con los profesionales y utilizando instrumentos de gestión y gobierno clínico”. No obstante, la Organización Médica Colegial afirma en el documento que su posición es inequívoca: “toca hablar y buscar soluciones reales” y “comprometerse en su puesta en práctica”. En la base de todas las propuestas efectuadas late la “exigencia de dar un protagonismo efectivo y de mayor alcance a la profesión médica y estudiar las fórmulas más eficaces para que ese liderazgo exista realmente y no provoque desconfianza ni impida la fluidez en la toma de decisiones” y cuestiona la multiplicación de órganos asesores en los que intervienen los médicos que “apenas son escuchados y, como mucho, reciben algunas explicaciones”. En la presentación del documento, se destaca que algunas administraciones como la de la Xunta de Galicia, han “maniobrado con acierto” para acotar los efectos negativos de algunas medidas y han llevado a cabo valiosas iniciativas, destacando la de la Xunta de introducir mayor racionalidad en el uso de los medicamentos, hasta un mayor esfuerzo por adoptar un enfoque más sensible con las necesidades de la profesión, por todo lo cual, la OMC considera “una oportunidad contar con la interlocución de un Gobierno sensible y confía en la generalización de esta actitud”.

CONSEJO GENERAL DE COLEGIOS OFICIALES DE MÉDICOS Se trata de un documento “crítico” en el que los médicos delimitan las “líneas rojas” que no deben sobrepasarse en esta situación de crisis y realizan sus propuestas para la sostenibilidad del SNS. Son 5 propuestas básicas son: 1º- La necesidad de un acuerdo político para la reforma del SNS que garantice su solvencia y que promueva un mayor protagonismo profesional en los niveles estratégicos de decisión para impedir que se instrumentalice la gestión por intereses partidistas. 2º) Una financiación estable y equilibrada para los distintos servicios de salud de las CCAA que determine y delimite el gasto sanitario público y lo protegiera con una estimación “per cápita”, ajustado por necesidad y recalculado periódicamente para cambios demográficos. 3º.-Promoción del Buen Gobierno del SNS a través de medidas legales y técnicas que aborden los problemas estructurales, entre ellas, un marco legal actualizado, una estructura agencial con bajo nivel de politización y alto nivel de trasparencia, y una institución profesional independiente que contribuya a evitar intervenciones asistenciales que no aporten valor al paciente y soporte la actividad de los profesionales con información objetiva, actualizada y debidamente contrastada. 4º.-Buen Gobierno y Buena Gestión en Centros y Servicios Sanitarios Público, avanzando en la creación de órganos colegiados de gobierno y en la profesionalización de la gestión, así como promover un rediseño de los servicios públicos de salud. En el documento se pone de manifiesto que el “Decálogo para el Buen Gobierno de los centros sanitarios y la profesionalización de la dirección” promovido por la OMC junto con SESPAS y SEDISA sigue siendo plenamente vigente. 5º.-Profesionalismo y creación de capital clínico, ético y gestor en las profesiones sanitarias que abarca un contrato 4

CONSEJO GENERAL DE COLEGIOS OFICIALES DE MÉDICOS social renovado con las profesiones sanitarias porque consideran que “es la cultura y no la economía, la que garantizará la sostenibilidad de los sistemas públicos de salud” y un pacto para gestionar la crisis sin descapitalizar la medicina. Finalmente, propone una reflexión conjunta con las autoridades sanitaria y el compromiso de “promover activamente el ahorro en el gasto sanitario” a cambio de no reducir en el empleo joven de médicos para lo cual se precisaría “avanzar en la agenda del Buen Gobierno, la autonomía responsable de la gestión y la restauración de la confianza entre las partes que ha quedado muy erosionada con la compulsión de acciones unilaterales de recorte”.

CONSEJO GENERAL DE COLEGIOS OFICIALES DE MÉDICOS

El secretario general de la OMC solicita a Echániz una rectificación inmediata El secretario general de la OMC, Serafin Romero, ha solicitado al Consejero de Sanidad de Castilla la Mancha, José Ignacio Echániz, una rectificación inmediata de sus declaraciones en relación a las “peonadas” en las que pone de manifiesto graves acusaciones contra los profesionales médicos a los que acusa de “realizar intervenciones innecesarias” a cambios de emolumentos económicos. • Ante las declaraciones del Consejero de Castilla la Mancha D. José Ignacio Echániz, que el miércoles dijo textualmente que los datos demuestran que los niveles de rendimiento en jornada de mañana eran muy inferiores a los de jornada de tarde e incluso ha apuntado que se “operaba a un número de personas por encima de los estándares de otros centros de otras comunidades autónomas” y con “indicaciones quirúrgicas por encima de lo necesario”, desde la corporación “solicitamos que se aclaren los términos referidos que, aunque pudiera entrar en una lógica de la variabilidad de la práctica clínica que se da en la profesión médica y en todos los ámbitos asistenciales, dejan entrever un tono acusador sobre posibles prácticas constitutivas de delito y realizadas sobre ciudadanos sin posible indicación para ello”. • Para el doctor Romero, estas desafortunadas declaraciones que se realizan en una situación grave de nuestro SNS se dirigen contra la profesión médica en 1

CONSEJO GENERAL DE COLEGIOS OFICIALES DE MÉDICOS general, sin definir quién, quienes y en donde se producen estas irregularidades, dejando entrever que la situación por la que atraviesa la sostenibilidad del modelo sanitario que tantas satisfacciones nos ha dado es debida a una mala práctica de todos los profesionales de la medicina. • Según el secretario general de la OMC, detrás de estas acusaciones contra los médicos, se encuentra también toda una grave acusación contra todos los Gerentes de las Instituciones Sanitarias de Castilla la Mancha que parece que ha estado mirando hacia otro lado y que son coparticipes por su ineficiencia e incompetencia, junto con los profesionales, de la gravísima situación de la Sanidad especialmente en esta Comunidad Autónoma. • Asegura que la sorpresa ha sido mayor tras haberse valorado positivamente el cambio de rumbo en las relaciones entre Consejería y profesionales con el objetivo de seguir dando a todos los ciudadanos de Castilla la Mancha una atención de calidad y sostenible, por lo que pide una rectificación inmediata de las citadas declaraciones.

Health at a Glance Europe 2012

Health at a Glance: Europe 2012

This work is published on the responsibility of the Secretary-General of the OECD. The opinions expressed and arguments employed herein do not necessarily reflect the official views of the OECD or of the governments of its member countries or those of the European Union. This document and any map included herein are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.

Please cite this publication as: OECD (2012), Health at a Glance: Europe 2012, OECD Publishing. http://dx.doi.org/10.1787/9789264183896-en

ISBN 978-92-64-18360-5 (print) ISBN 978-92-64-18389-6 (HTML)

Series: Health at a Glance: Europe ISSN 2305-607X (print) ISSN 2305-6088 (online)

European Union Catalogue number: ND-32-12-458-EN-C (print) Catalogue number: ND-32-12-458-EN-N (PDF) ISBN 978-92-79-26063-6 (print) ISBN 978-92-79-26062-9 (PDF)

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FOREWORD

Foreword

his second edition of Health at a Glance: Europe presents the most recent key indicators of health and health systems across 35 countries: the 27 European Union member states, five candidate countries and three European Free Trade Association countries. The report comes at a difficult time for European health systems. The economic crisis is increasing poverty, unemployment and stress, all of which are associated with worse health outcomes, yet public and private budgets are under great strain. The report highlights the marked slowdown (sometimes even reduction) in health spending over recent years in many countries, as part of broader efforts to reduce large budgetary deficits. If the report does not yet show any worsening health outcomes due to the crisis, there is no cause for complacency – it takes time for poor social conditions or poor quality care to take its toll from people’s health. Policy makers have often done what they could to ensure that access to high quality care remains the norm in Europe; whether this is enough to protect the health of the population will only become clear in years to come. The indicators presented in this report are based largely on the European Community Health Indicators (ECHI), a set of indicators used by the European Commission to guide the development of health information systems in Europe. Additional indicators examine health expenditure trends as well as quality of care, building on OECD expertise in these domains. The publication at hand reflects the long and fruitful collaboration between the OECD and the European Commission in the development and reporting of health statistics. Since 2005, a joint data collection between the OECD, the European Commission and the World Health Organization has improved the availability of comparable data on health expenditure, based on a common System of Health Accounts. Furthermore, since 2010, these three organisations have gathered additional data on the health workforce as well as on the physical and technical resources required to deliver health services. The OECD and the European Commission will continue to work closely together to improve the quality and comparability of data to monitor population health and the performance of health systems across European countries. In the meantime, we hope that this publication will be useful to you and that it will stimulate action to improve the health of European citizens by learning from each others’ experience.

Yves Leterme Deputy Secretary-General Organisation for Economic Co-operation and Development

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

Paola Testori Coggi Director-General Directorate-General for Health and Consumers European Commission

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 Gaétan Lafortune and Michael de Looper. Chapter 1 and Chapter 2 were prepared by Michael de Looper; Chapter 3 by Gaétan Lafortune and Gaëlle Balestat; Chapter 4 by Kees van Gool and Nelly Biondi, under the supervision of Niek Klazinga; and Chapter 5 by Michael Mueller and David Morgan. A large part of the data presented in this publication come from the two annual data collections on health accounts and non-monetary health care statistics carried out jointly by the OECD, Eurostat and WHO. It is important to recognise the work of colleagues from Eurostat (Elodie Cayotte) and WHO Europe (Ivo Rakovac and Natela Nadareishvili) who have contributed to validating some of the data presented in this publication, to ensure that they meet the highest standards of quality and comparability. The OECD would also like to recognise the contribution of Mika Gissler, from the National Institute for Health and Welfare in Finland and the leader of the former Joint Action on the European Community Health Indicators Monitoring project, for providing useful guidance and advice on the content of this publication. Thanks also go to Jürgen Thelen from the Robert Koch Institute for assistance with data on adult fruit and vegetable consumption, and Jean-Marie Robine and Carol Jagger (European Joint Action on Healthy Life Years: EHLEIS) for their contribution on the healthy life years indicator. This publication benefited from comments from Mark Pearson (Head of OECD Health Division). Many useful comments were also received from Stefan Schreck, Boriana Goranova and Fabienne Lefebvre from the European Commission (DG SANCO, Health Information Unit), as well as from officials in other DG SANCO Units.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

TABLE OF CONTENTS

Table of contents Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 . . . . . . . . . . . . . . . . . . . 1.3. Mortality from all causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4. Mortality from heart disease and stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5. Mortality from cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6. Mortality from transport accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7. Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8. Infant mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9. Infant health: Low birth weight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.10. Self-reported health and disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.11. Incidence of selected communicable diseases . . . . . . . . . . . . . . . . . . . . . . . . . . 1.12. HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.13. Cancer incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16 18 20 22 24 26 28 30 32 34 36 38 40

1.14. Diabetes prevalence and incidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.15. Dementia prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.16. Asthma and COPD prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

42 44 46

Chapter 2. 2.1. 2.2. 2.3. 2.4. 2.5. 2.6. 2.7. 2.8. Chapter 3. 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. 3.7. 3.8.

Determinants of health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Smoking and alcohol consumption among children . . . . . . . . . . . . . . . . . . . . . Overweight and obesity among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fruit and vegetable consumption among children. . . . . . . . . . . . . . . . . . . . . . . Physical activity among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Smoking among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alcohol consumption among adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overweight and obesity among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fruit and vegetable consumption among adults . . . . . . . . . . . . . . . . . . . . . . . .

50 52 54 56 58 60 62 64

Health care resources and activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Consultations with doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical technologies: CT scanners and MRI units . . . . . . . . . . . . . . . . . . . . . . . Hospital beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hospital discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Average length of stay in hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cardiac procedures (coronary angioplasty) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

68 70 72 74 76 78 80 82

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

TABLE OF CONTENTS

3.9. Cataract surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.10. Hip and knee replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.11. Pharmaceutical consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.12. Unmet health care needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 4.

84 86 88 90

Quality of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Care for chronic conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Avoidable admissions: Respiratory diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Avoidable admissions: Uncontrolled diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . .

94 94 96

Acute care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 4.3. In-hospital mortality following acute myocardial infarction . . . . . . . . . . . . . . 98 4.4. In-hospital mortality following stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 4.5. Procedural or postoperative complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 4.6. Obstetric trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Cancer care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.7. Screening, survival and mortality for cervical cancer . . . . . . . . . . . . . . . . . . . . 4.8. Screening, survival and mortality for breast cancer. . . . . . . . . . . . . . . . . . . . . . 4.9. Screening, survival and mortality for colorectal cancer . . . . . . . . . . . . . . . . . .

106 106 108 110

Care for communicable diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 4.10. Childhood vaccination programmes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 4.11. Influenza vaccination for older people. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Chapter 5. 5.1. 5.2. 5.3. 5.4. 5.5. 5.6. 5.7.

Health expenditure and financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Coverage for health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health expenditure per capita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health expenditure in relation to GDP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health expenditure by function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pharmaceutical expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Financing of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trade in health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

118 120 122 124 126 128 130

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Annex A.

Additional information on demographic and economic context . . . . . . . . 143

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HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

Health at a Glance: Europe 2012 ÂŠ OECD 2012

Executive summary

uropean countries have achieved major gains in population health in recent decades. Life expectancy at birth in European Union (EU) member states has increased by more than six years since 1980, to reach 79 years in 2010, while premature mortality has reduced dramatically. Over three-quarters of these years of life can be expected to be lived free of activity limitation. Gains in life expectancy can be explained by improved living and working conditions and some health-related behaviours, but better access to care and quality of care also deserves much credit, as shown, for instance, by sharply reduced mortality rates following a heart attack or stroke. Many health improvements have come at considerable financial cost. Until 2009, health spending in European countries grew at a faster rate than the rest of the economy, and the health sector absorbed a growing share of the gross domestic product (GDP). Following the onset of the financial and economic crisis in 2008, many European countries reduced health spending as part of broader efforts to reign in large budgetary deficits and growing debt-to-GDP ratios. Although these cuts might have been unavoidable, some measures may have an impact on the fundamental goals of health systems. Continuous monitoring of data and indicators on health and health systems is therefore important; it provides indications of the potential short and longer-term impact of changing economic circumstances and health policies on health care access, quality and health outcomes. This second edition of Health at a Glance: Europe presents the most recent comparable data for selected indicators of health and health systems in 35 European countries â&#x20AC;&#x201C; the 27 member states of the European Union, five candidate countries and three EFTA countries â&#x20AC;&#x201C; up to 2010. The selection of indicators has been based on the European Community Health Indicators (ECHI) shortlist, a list of indicators that has been developed by the European Commission to guide the development and reporting of health statistics. In addition, the publication provides detailed information on health expenditure and financing trends, using results from the OECD, Eurostat and WHO annual joint health accounts questionnaire. It also includes a new chapter on quality of health care, reflecting the progress achieved under the OECD Health Care Quality Indicators project. The data presented here come mainly from official national statistics, collected individually or jointly by the OECD, Eurostat or WHO-Europe, as well as multi-country surveys such as the Health Behaviour in School-aged Children (HBSC) survey. Health at a Glance: Europe 2012 presents trends over time and variations across European countries under five broad topics: 1) population health status; 2) risk factors to health; 3) resources and activities of health care systems; 4) quality of care for chronic and acute conditions; and 5) health expenditure and financing sources. It offers some explanation for these variations, providing background for further research and analysis to understand more fully the causes underlying such variations and to develop policy options to reduce gaps with those countries that are achieving better results. Many indicators provide a breakdown by sex and age in each country, and several include a further breakdown by

EXECUTIVE SUMMARY

income or education levels. These indicators show that there may be as much variation within a country by sub-national regions, socio-economic groups or ethnic/racial groups as there is across countries.

Health status has improved dramatically in European countries, although large gaps persist ●

Life expectancy at birth in EU member states has increased by over 6 years between 1980 and 2010. On average across the European Union, life expectancy at birth for the three-year period 2008-10 was 75.3 years for men and 81.7 years for women. France had the highest life expectancy for women (85.0 years), and Sweden for men (79.4 years). Life expectancy at birth in the EU was lowest in Bulgaria and Romania for women (77.3 years) and Lithuania for men (67.3 years). The gap between EU member states with the highest and lowest life expectancies at birth is around 8 years for women and 12 years for men (Figure 1.1.1).

●

On average across the European Union, healthy life years (HLY) at birth, defined as the number of years of life free of activity limitation, was 62.2 years for women and 61.0 years for men in 2008-10. The gender gap is much smaller than for life expectancy, reflecting the fact that a higher proportion of the life of women is spent with some activity limitations. HLY at birth in 2008-10 was greatest in Malta for women and Sweden for men, and shortest in the Slovak Republic for both women and men (Figure 1.1.1).

●

Life expectancy at age 65 has also increased substantially in European countries, averaging 16.5 years for men and 20.1 years for women in the European Union in 2008-10. As for life expectancy at birth, France had the highest life expectancy at age 65 for women (23.2 years) but also for men (18.7 years). Life expectancy at age 65 in the European Union was lowest in Bulgaria for women (16.9 years) and Latvia for men (13.2 years) (Figure 1.2.1).

●

Large inequalities in life expectancy persist between socio-economic groups. For both men and women, highly educated persons are likely to live longer; in the Czech Republic for example, 65-year-old men with a high level of education can expect to live seven years longer than men of the same age with a low education level (Figure 1.2.3).

●

It is difficult to estimate the relative contribution of the numerous non-medical and medical factors that might affect variations in life expectancy across countries. Higher national income is generally associated with higher (healthy) life expectancy, although the relationship is less pronounced at the highest income levels, suggesting a “diminishing return” (Figure 1.1.2).

●

Chronic diseases such as diabetes, asthma and dementia are increasingly prevalent, due either to better diagnosis or more underlying disease. More than 6% of people aged 20-79 years in the European Union, or 30 million people, had diabetes in 2011 (Figure 1.14.1). Better management of chronic diseases has become a health policy priority for many EU member states.

Risk factors to health are changing ●

Most European countries have reduced tobacco consumption via public awareness campaigns, advertising bans and increased taxation. The percentage of adults who smoke daily is below 15% in Sweden and Iceland, from over 30% in 1980. At the other end of the scale, over 30% of adults in Greece smoke daily. Smoking rates continue to be high in Bulgaria, Ireland and Latvia (Figure 2.5.1).

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

EXECUTIVE SUMMARY

●

Alcohol consumption has also fallen in many European countries. Curbs on advertising, sales restrictions and taxation have all proven to be effective measures. Traditional wine-producing countries, such as France, Italy and Spain, have seen consumption per capita fall substantially since 1980. Alcohol consumption per adult rose significantly in a number of countries, including Cyprus, Finland and Ireland (Figure 2.6.1).

●

In the European Union, 52% of the adult population is now overweight, of which 17% is obese. At the country level, the prevalence of overweight and obesity exceeds 50% in 18 of the 27 EU member states. Rates are much lower in France, Italy and Switzerland, although increasing there as well. The prevalence of obesity – which presents greater health risks than overweight – ranges from 8% in Romania and Switzerland to over 25% in Hungary and the United Kingdom (Figure 2.7.1). The obesity rate has doubled since 1990 in many European countries (Figure 2.7.2). Rising obesity has affected all population groups, to varying extents. Obesity tends to be more common among disadvantaged social groups, and especially women.

The number of doctors and nurses per capita is higher than ever before in most countries, but there are concerns about current or future shortages ●

Ensuring proper access to health care is a fundamental policy objective in all EU member states. It requires, among other things, having the right number of health care providers in the right places to respond to the population’s needs. There are concerns in many European countries about shortages of doctors and nurses, although recent public spending cuts on health in some countries may have led to at least a temporary reduction in demand.

●

Since 2000, the number of doctors per capita has increased in almost all EU member states. On average across the European Union, the number of doctors grew from 2.9 per 1 000 population in 2000 to 3.4 in 2010. Growth was particularly rapid in Greece and the United Kingdom (Figure 3.1.1).

●

In nearly all countries, the balance between generalist and specialist doctors has changed such that there are now more specialists (Figure 3.1.2). This may be explained by a reduced interest in traditional “family medicine” practice, combined with a growing remuneration gap between generalists and specialists. The slow growth or reduction in the number of generalists raises concerns in many countries about access to primary care for certain population groups.

●

There are also concerns about possible shortages of nurses, and this may well intensify in the future as the demand for nurses continues to increase and the ageing of the “baby boom” generation precipitates a wave of retirements among nurses. Over the past decade, the number of nurses per capita has increased in nearly all EU member states (Figure 3.3.1). The increase was particularly large in Demark, France, Portugal and Spain. However, recently there has been a reduction in nurses employed in some countries hardest hit by the economic crisis. In Estonia, the number of nurses increased to 2008, but has decreased since then, with a resulting fall from 6.4 per 1 000 population in 2008 to 6.1 in 2010.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

EXECUTIVE SUMMARY

Quality of care has improved in most European countries, though all countries can do better, particularly to avoid hospital admissions for people with chronic diseases ●

There has been progress in the treatment of life-threatening conditions such as heart attack, stroke and cancer in all reporting European countries. Mortality rates following hospital admissions for heart attack (acute myocardial infarction) have fallen by nearly 50% between 2000 and 2009 (Figure 4.3.3) and for stroke by over 20% (Figure 4.4.3). These improvements reflect better acute care and greater access to dedicated stroke units in countries like Denmark and Sweden.

●

Survival rates for different types of cancer have also improved in most countries, reflecting earlier detection and greater treatment effectiveness (Figures 4.7.2 and 4.8.2). While survival rates for breast cancer remain below 80% in the Czech Republic and Slovenia, they have increased by over 10 percentage points between 1997-2002 and 2004-09. These two countries also witnessed substantial gains in survival rates for colorectal cancer (Figure 4.9.2).

●

It is more difficult to monitor quality of care in the primary care sector, as in most countries there are fewer data than in the hospital sector. Avoidable hospital admission is often used as an indicator of either access problems to primary care or the quality and continuity of care. There is general consensus that asthma and diabetes should largely be managed through proper primary care interventions to avoid exacerbation and costly hospitalisation. While hospital admissions for asthma are low in certain countries, they are much higher in others, such as the Slovak Republic (Figure 4.1.1). In all European countries, there are too many hospital admissions for uncontrolled diabetes (Figure 4.2.1).

Growth in health expenditure has slowed or fallen in many European countries

●

Growth in health spending per capita slowed or fell in real terms in 2010 in almost all European countries, reversing a trend of steady increases. Spending had already started to fall in 2009 in countries hardest hit by the economic crisis (e.g. Estonia and Iceland), but this was followed by deeper cuts in 2010 in response to growing budgetary pressures and rising debt-to-GDP ratios. On average across the EU, health spending per capita increased by 4.6% per year in real terms between 2000 and 2009, followed by a fall of 0.6% in 2010 (Figure 5.2.2).

●

Reductions in public spending on health were achieved through a range of measures, including reductions in wages and/or employment levels, increasing direct payments by households for certain services and pharmaceuticals, and imposing severe budget constraints on hospitals. Gains in efficiency have also been pursued through mergers of hospitals or accelerating the move from inpatient care to outpatient care and day surgery.

●

As a result of the negative growth in health spending in 2010, the percentage of GDP devoted to health stabilised or declined slightly in many EU member states. In 2010, EU member states devoted on average 9.0% (unweighted) of their GDP to health spending (Figure 5.3.1), up significantly from 7.3% in 2000, but down slightly from the peak of 9.2% in 2009.

●

The Netherlands allocated the highest share of GDP to health in 2010 (12%), followed by France and Germany (both at 11.6%). In terms of health spending per capita, the Netherlands (EUR 3 890), Luxembourg (EUR 3 607) and Denmark (EUR 3 439) were the

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

EXECUTIVE SUMMARY

highest spenders among EU member states. Austria, France and Germany followed, at over EUR 3 000 per capita. Bulgaria and Romania were the lowest spending countries, at around EUR 700. ●

The public sector is the main source of health care financing in all European countries, except Cyprus (Figure 5.6.1). In 2010, nearly three-quarter (73%) of all health spending was publicly financed on average in EU member states. Public financing accounted for over 80% in the Netherlands, the Nordic countries (except Finland), Luxembourg, the Czech Republic, the United Kingdom and Romania. The share was the lowest in Cyprus (43%), and Bulgaria, Greece and Latvia (55-60%).

●

The economic crisis has affected the mix of public and private health financing in some countries. Public spending has been cut for certain goods and services, often combined with increases in the share of direct payments by households. In Ireland, the share of public financing of health spending decreased by nearly 6 percentage points between 2008 and 2010, and stands now at 70%, while the share of out-of-pocket payments by households increased. There have also been substantial falls in Bulgaria and the Slovak Republic.

●

After public financing, the main source of funding for health expenditure in most countries is out-of-pocket payments. Private health insurance financing only plays a significant role in a few countries. In 2010, the share of out-of-pocket payments was highest in Cyprus (49%), Bulgaria (43%) and Greece (38%). It was the lowest in the Netherlands (6%), France (7%) and the United Kingdom (9%). Its share has increased over the past decade in about half of EU member states, most notably in Bulgaria, Cyprus, Malta and the Slovak Republic (Figure 5.6.3).

●

The economic crisis and growing budgetary constraints have put additional pressures on health systems in many European countries. Several countries that have been hardest hit by the crisis have taken a series of measures to reduce public spending on health. It will be important to monitor closely the short and longer-term impact of these measures on the fundamental goals of health systems in European countries of ensuring proper access and quality of care.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

INTRODUCTION

Introduction

ealth at a Glance: Europe 2012 presents key indicators of health and health systems in 35 European countries, including the 27 European Union member states, 5 candidate countries and 3 European Free Trade Association countries. The selection of indicators is based largely on the European Community Health Indicators (ECHI) shortlist, a set of indicators that has been developed to guide the reporting of health statistics in the European Union (ECHIM, 2012). It is complemented by additional indicators on health expenditure and quality of care in the related chapters. The first edition of this report was released in 2010. This second edition includes a larger number of ECHI indicators (notably in the first chapter on health status and in the chapter on health care resources and activities), reflecting progress in data availability and comparability. There is also a new chapter on quality of care combining certain ECHI indicators with selected indicators on quality of care and patient safety developed under the OECD Health Care Quality Indicators project (OECD, 2010c). The data presented in this publication are mostly official national statistics and have been collected through questionnaires administered by the OECD, Eurostat and WHO. The data have been validated by the three organisations to ensure that they meet standards of data quality and comparability. In certain cases, the data come from regular cross-national surveys, such as the Health Behaviour in School-aged Children surveys for the set of indicators on health risk factors among children. All indicators are presented in the form of easy-to-read figures and explanatory text, based on a two-page format per indicator.

Structure of the publication The publication is structured around five chapters:

●

Chapter 1 on Health status highlights the variations across countries in life expectancy and healthy life expectancy, and also presents other indicators of causes of mortality and morbidity, including both communicable and non-communicable diseases.

●

Chapter 2 on Determinants of health focuses on non-medical determinants of health related to modifiable lifestyles and behaviours among children and adults, such as smoking and alcohol drinking, nutrition, physical activity, and overweight and obesity.

●

Chapter 3 on Health care resources and activities reviews some of the inputs and outputs of health care systems, including the supply of doctors and nurses, different types of equipment used for diagnosis or treatment, and the provision of a range of services to prevent the transmission of communicable diseases or to treat acute conditions.

●

Chapter 4 is a new chapter on Quality of care, providing comparisons on care for chronic and acute conditions, cancers and communicable diseases. The chapter also includes a set of indicators on patient safety, building on the developmental work and data collection carried out under the OECD Health Care Quality Indicators project.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

INTRODUCTION

●

Chapter 5 on Health expenditure and financing examines trends in health spending across European countries, both overall and for different types of health services and goods, including pharmaceuticals. It also looks at how these health services and goods are paid for and the different mix between public funding, private health insurance, and direct out-of-pocket payments by households.

An annex provides some additional tables on the demographic and economic context within which different health systems operate, as well as additional data on health expenditure trends.

Presentation of indicators Each of the topics covered in this publication is presented over two pages. The first provides a brief commentary highlighting the key findings conveyed by the data, defines the indicator(s) and discusses any significant national variations from that definition which might affect data comparability. On the facing page is a set of figures. These typically show current levels of the indicator and, where possible, trends over time. In some cases, an additional figure relating the indicator to another variable is included. The average in the figures includes only European Union (EU) member states, and is calculated as the unweighted average of those EU member states presented (up to 27, if there is full data coverage). Some weighted averages are also presented in the tables on health expenditure and GDP in the annex.

Data and limitations Limitations in data comparability are indicated both in the text (in the box related to “Definition and comparability”) as well as in footnotes to charts. Readers interested in using the data presented in this publication for further analysis and research are encouraged to consult the full documentation of definitions, sources and methods contained in OECD Health Data 2012 for all OECD member countries, including 21 EU member states and 4 additional countries (Iceland, Norway, Switzerland and Turkey). This information is available on OECD.Stat (http://stats.oecd.org/index.aspx?DataSetCode= HEALTH_STAT). For ten other countries (Bulgaria, Croatia, Cyprus, Former Yugoslav Republic of Macedonia, Latvia, Lithuania, Malta, Montenegro, Romania and Serbia), readers should consult the Eurostat database for more information on sources and methods: http:// epp.eurostat.ec.europa.eu/portal/page/portal/statistics/search_database. Readers interested in an interactive presentation of the ECHI indicators can also consult the DG SANCO HEIDI data tool at: http://ec.europa.eu/health/indicators/indicators/index_en.htm.

Population figures The population figures for all EU member states and candidate countries presented in the annex and used to calculate rates per capita in this publication come from the Eurostat demographics database. The data were extracted in June 2012, and relate to mid-year estimates (calculated as the average between the beginning and end of year population figures). Population estimates are subject to revision, so they may differ from the latest population figures released by Eurostat or national statistical offices. Some member states such as France and the United Kingdom have overseas colonies, protectorates and territories. These populations are generally excluded. However, the calculation of GDP per capita and other economic measures may be based on a different population in these countries, depending on the data coverage. HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

INTRODUCTION

Country codes (ISO codes) Austria

AUT

Lithuania

LTU

Belgium

BEL

Luxembourg

LUX

Bulgaria

BGR

Malta

MLT

Croatia

HRV

Montenegro

MNE

Cyprus1

CYP

Netherlands

NLD

Czech Republic

CZE

Norway

NOR

Denmark

DNK

Poland

POL

Estonia

EST

Portugal

PRT

Finland

FIN

Romania

ROU

France

FRA

Serbia

SRB

FYR of Macedonia

MKD

Slovenia

SVN

Germany

DEU

Slovak Republic

SVK

Greece

GRC

Spain

ESP

Hungary

HUN

Sweden

SWE

Iceland

ISL

Switzerland

CHE

Ireland

IRL

Turkey

TUR

Italy

ITA

United Kingdom

GBR

Latvia

LVA

1. Note by Turkey: The information in this document with reference to “Cyprus” relates to the southern part of the Island. There is no single authority representing both Turkish and Greek Cypriot people on the Island. Turkey recognises the Turkish Republic of Northern Cyprus (TRNC). Until a lasting and equitable solution is found within the context of United Nations, Turkey shall preserve its position concerning the “Cyprus” issue. Note by all the European Union member states of the OECD and the European Commission: The Republic of Cyprus is recognised by all members of the United Nations with the exception of Turkey. The information in this document relates to the area under the effective control of the Government of the Republic of Cyprus.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

Health at a Glance: Europe 2012 ÂŠ OECD 2012

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

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

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

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

1.16. Asthma and COPD prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.1. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT BIRTH

Life expectancy at birth continues to increase in European countries, reflecting reductions in mortality rates at all ages. These gains in longevity can be attributed to a number of factors, including rising living standards, improved lifestyle and better education, as well as greater access to quality health services. Better nutrition, sanitation and housing also play a role, particularly in countries with developing economies (OECD, 2011b). Average life expectancy at birth for 2008-10 across the 27 member states of the European Union reached 75.3 years for men and 81.7 years for women (Figure 1.1.1), a rise of 2.7 and 2.3 years respectively over the decade from 1998-2010. In more than two-thirds of EU member states, life expectancy exceeded 80 years for women and 75 years for men. France had the highest life expectancy at birth for women in 2008-10 (85.0 years), and Sweden for men (79.4 years). Life expectancy was lowest in Bulgaria and Romania for women (77.3 years) and in Lithuania for men (67.3 years). The gap between EU member states with the highest and lowest life expectancies is around eight years for women and 12 years for men. The gender gap in life expectancy at birth in 2008-10 stood at 6.4 years, around half a year less than a decade earlier. However, this hides a large range among countries, with the smallest gap in Sweden, the Netherlands and the United Kingdom, along with Iceland (about four years) and the largest in Lithuania (over 11 years). The recent narrowing of this gap in most countries can be attributed at least partly to the narrowing of differences in risk-increasing behaviours between men and women, such as smoking, accompanied by sharp reductions in mortality rates from cardiovascular diseases among men. Looking ahead, Eurostat projects that life expectancy will continue to increase in the European Union in coming decades, to reach 84.6 years for males and 89.1 for females in 2060. Convergence among countries is expected to continue, with the largest increases in life expectancy to take place in those countries with the lowest life expectancy in 2010 (EC, 2012a). In a context of increasing life expectancy and population ageing, healthy life years (HLY) has been endorsed as an important European policy indicator to address whether years of longer life are lived in good health (Joint Action: EHLEIS, 2012). The current leading indicator of HLY is a measure of disability-free life expectancy which indicates how long people can expect to live without disability. On average for EU member states, HLY at birth in 2008-10 was 62.2 years for women and 61.0 years for men. It was greatest in Malta for women, and in Sweden for men, and shortest in the Slovak Republic for both men and women (Figure 1.1.1). Women in Malta can expect to live 86% of life expectancy without limitations in usual activities. For men in Sweden, the value is even higher at 89%. In the Slovak Republic, only 66% of female and 73% of male life expectancy is free from activity limitation. The spread of values for HLY at birth among EU member states are much greater than for life expectancy, being 19 years for women and 18 years for men.

Since the HLY indicator has only recently been developed, there is as yet no long time series. In contrast to the 6.4 year gap in life expectancy at birth for EU member states on average, the gender gap in HLY at birth was only around 1.2 years in 2008-10. For life expectancy at birth the gender gap has always favoured women. However, seven countries had a gender gap in HLY which favoured men, the greatest being 2.0 more HLY for men in Portugal. Of the remaining countries, Lithuania had the largest gender gap in HLY favouring women. The European Innovation Partnership on Active and Healthy Ageing, part of the Europe 2020 initiative, has set an objective of increasing the average number of healthy life years by two, by 2020 (EC, 2011b). A wide range of factors affect life expectancy and HLY. Higher national income (as measured by GDP per capita) is generally associated with higher life expectancy at birth and also with HLY, although the relationship is less pronounced at higher levels of national income (Figure 1.1.2). Similarly, Figure 1.1.3 shows that higher health spending per capita tends to be associated with higher HLY, although there is much variation for a given level of health spending, confirming that many other factors play a role in determining the number of healthy life years.

Definition and comparability Life expectancy measures how long, on average, people would live based on a given set of age-specific death rates. However, the actual age-specific death rates of any particular birth cohort cannot be known in advance. If age-specific death rates are falling (as has been the case over the past decades), actual life spans will, on average, be higher than life expectancy calculated with current death rates. Healthy life years (HLY) are the number of years spent free of activity limitation, being equivalent to disability-free life expectancy. HLY are calculated annually by Eurostat and EHLEIS for each EU country using the Sullivan (1971) method. The underlying health measure is the Global Activity Limitation Indicator (GALI), which measures limitation in usual activities, and comes from the European Union Statistics on Income and Living Conditions (EU-SILC) survey. Comparing trends in HLY and life expectancy can show whether extra years of life are healthy years. However, valid comparisons depend on the underlying health measure being truly comparable. While HLY is the most comparable indicator to date, there are still problems with translation of the GALI question, although it does appear to satisfactorily reflect other health and disability measures (Jagger et al., 2010).

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

1.1. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT BIRTH

1.1.1. Life expectancy (LE) and healthy life years (HLY) at birth, by gender, 2008-10 average HLY

LE with activity limitation

Life expectancy

Females

Males France Spain Italy Sweden Finland Cyprus Austria Luxembourg Malta Germany Netherlands Slovenia Belgium Ireland Greece Portugal United Kingdom EU27 Denmark Czech Republic Poland Estonia Slovak Republic Hungary Lithuania Latvia Romania Bulgaria

85.0 84.9 84.6 83.5 83.4 83.4 83.3 83.3 82.9 82.8 82.8 82.8 82.8 82.7 82.6 82.6 82.3 81.7 81.2 80.6 80.3 80.2 79.1 78.4 78.4 78.1 77.3 77.3

78.7 79.3 79.4 76.7 78.6 77.8 78.0 78.1 77.8 78.7 75.9 77.3 78.0 78.0 76.5 78.2 75.3 76.9 74.3 71.6 69.7 71.3 70.3 67.3 67.9 69.8 70.1

Switzerland Iceland Norway Croatia Turkey Montenegro FYR of Macedonia Serbia

84.7 83.7 83.2 79.9 78.8 78.0 76.8 76.8

90 Years

78.0

80.0 79.9 78.7 73.5 73.3 73.1 72.5 71.5

90 Years

Source: Eurostat Statistics Database; Joint Action: EHLEIS (2012).

1 2 http://dx.doi.org/10.1787/888932702879

1.1.2. Healthy life years (HLY) at birth and GDP per capita, 2008-10 average

1.1.3. Healthy life years (HLY) at birth and health spending per capita, 2008-10 average

HLY (years) 75

HLY (years) 75 R 2 = 0.21 MLT

SWE

BGR

CZE POL

CYP ESP

GBR IRL

NOR

ISL GRC

BEL

LUX

SWE NOR

ISL GRC

GBR

CYP

BGR

CHE ROU

DNK ITA ROU NLD FRA AUT HRV FIN SVN LTU PRT DEU HUN EST LVA

R 2 = 0.15 MLT

POL

HUN

EST

ITA

LUX

IRL BEL

CHE

FRA DNK NLD

HRV

LTU 55

CZE

ESP

AUT

SVN FIN PRT

DEU

LVA

SVK

50 0

20 000

40 000

60 000 GDP per capita (EUR PPP)

Source: Eurostat Statistics Database; OECD Health Data 2012; WHO Global Health Expenditure Database. 1 2 http://dx.doi.org/10.1787/888932702898

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

1 000

2 000

3 000 4 000 5 000 Health spending per capita (EUR PPP)

Source: Eurostat Statistics Database; OECD Health Data 2012; WHO Global Health Expenditure Database. 1 2 http://dx.doi.org/10.1787/888932702917

1.2. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT AGE 65

Life expectancy at age 65 has increased significantly among both women and men over the past several decades in all EU member states. Some of the factors explaining the gains in life expectancy at age 65 include advances in medical care, greater access to health care, healthier lifestyles and improved living conditions before and after people reach age 65. The average life expectancy at age 65 in 2008-10 for the 27 member states of the European Union was 16.5 years for men and 20.1 years for women (Figure 1.2.1). As for life expectancy at birth, France had the highest life expectancy at age 65 for women (23.2 years), but also for men (18.7 years). Among other countries, life expectancy at 65 was highest in Switzerland for both men and women. Life expectancy at age 65 in the European Union was lowest in Latvia for men (13.2 years) and in Bulgaria for women (16.9 years). The average gender gap in life expectancy at age 65 in 2008-10 stood at 3.6 years, unchanged since 1998-2000. Greece had the smallest gender gap of 2 years and Estonia the largest at 5.2 years. Gains in longevity at older ages in recent decades, combined with the trend reduction in fertility rates are contributing to a steady rise in the proportion of older persons (see Annex Table A.2). Whether longer life expectancy is accompanied by good health and functional status among ageing populations has important implications for health and long-term care systems. Healthy life years (HLY) at age 65 in 2008-10 for EU member states was similar for men and women, being 8.4 years for men and 8.6 years for women. HLY at age 65 in 2008-10 was greatest in Sweden and shortest in the Slovak Republic for both men and women (Figure 1.2.1). HLY is based on the Global Activity Limitation (GALI) question, which is one of three indicators included in the Minimum European Health Module along with global items on self-perceived health and chronic morbidity. Since the HLY indicator has only been developed relatively recently, there is as yet no long time series. The relationship between life expectancy and HLY at age 65 is not clear-cut (Figure 1.2.2). Higher life expectancy at age 65 is generally associated with higher HLY, although longer life expectancy at age 65 does not necessarily imply more HLY. Central and Eastern European countries have both lower life expectancy and HLY than other European countries. Life expectancy at age 65 years also varies by educational status (Figure 1.2.3). For both men and women, highly educated people are likely to live longer (Corsini, 2010). Again, differences in life expectancy are particularly large in Central and Eastern European countries, and are more pronounced for men. In the Czech Republic, 65-year-old men with a high level of education can expect to live seven years longer than those with a low education level. Not only is

education a general measure of socio-economic status, it can also provide the means to improve the social and economic conditions in which people live and work. A recent study showed that higher educational levels are not only associated with higher life expectancy but also with higher disability-free life expectancy at age 65 in ten EU member states. For both men and women, differences were larger for disability-free life expectancy than life expectancy (Majer et al., 2011). In several European countries, occupation is used as a measure of socio-economic status. In the United Kingdom for the period 2002-06, 65-year-old men classified as “Higher managerial and professional” could expect to live 3.5 years longer than men in “Routine occupations”, and this gap had widened over the previous two decades. The gap for women was similar at 3.2 years. In France, in 2003, 65-year-old men who had highly qualified occupations could expect to live 3.1 years longer in total and 3.7 years longer without disability than men who were manual workers. These gaps were respectively 1.7 years and 3.2 years for women (Cambois et al., 2011).

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.2. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT AGE 65

1.2.1. Life expectancy (LE) and healthy life years (HLY) at 65, by gender, 2008-10 average HLY

LE with activity limitation

Life expectancy

Females

Males France Spain Italy Finland Luxembourg Austria Belgium Sweden Netherlands Germany United Kingdom Ireland Slovenia Cyprus Malta Portugal Greece EU27 Denmark Poland Estonia Czech Republic Lithuania Hungary Latvia Slovak Republic Romania Bulgaria

23.2 22.4 22.1 21.4 21.3 21.2 21.1 21.1 20.9 20.8 20.7 20.7 20.7 20.7 20.6 20.5 20.1 20.1 19.6 19.3 19.2 18.9 18.3 18.2 18.1 17.9 17.2 16.9

21.1 21.0 18.4 18.2 17.0 16.1 15.8

18.3 17.4 17.4 17.8 17.5 18.2 17.6 17.6 18.0 17.4 16.5 18.0 17.4 17.0 18.1 16.5 16.8 14.9 13.9 15.3 13.4 14.0 13.2 14.0 14.0 13.6

Switzerland Norway Iceland Turkey Croatia Montenegro Serbia FYR of Macedonia

22.3

25 Years

18.7 18.3

19.0 17.9 18.4 15.2 14.6 14.8 13.9 13.8

25 Years

Source: Eurostat Statistics Database; Joint Action: EHLEIS (2012).

1 2 http://dx.doi.org/10.1787/888932702936

1.2.2. Relationship between life expectancy and healthy life years (HLY) at 65, 2008-10 average

1.2.3. Life expectancy gaps between high and low education attainment at 65, women and men, 2010 (or nearest year) Men

Healthy life years (HLY) 16 R 2 = 0.37 NOR

SWE ISL

DNK

12 10

LUX BEL

IRL BGR

POL

LTU

NLD CYP

SVN

ROU

CZE

GRC

FIN AUT

ESP

FRA

ITA

DEU

HRV HUN EST

LVA

CHE

GBR

MLT

PRT

SVK 0 16

Bulgaria Czech Republic Denmark Estonia Finland Hungary Italy Malta Poland Portugal Romania Slovenia Sweden Croatia FYR of Macedonia Norway

Women

20 22 Life expectancy (years)

Source: Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932702955

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

8 Years

Source: Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932702974

1.3. MORTALITY FROM ALL CAUSES

Statistics on deaths remain one of the most widely available and comparable sources of information on health. Registering deaths is compulsory in all European countries, and the data collected through the process of registration can be used by statistical and health authorities to monitor diseases and health status, and to plan health services. In order to compare levels of mortality across countries and over time, the data need to be standardised to remove the effect of differences in age structure. In 2010 there were large variations in age-standardised mortality rates for all causes of death across European countries. Death rates were lowest in Spain and Italy, at less than 500 deaths per 100 000 population (Figure 1.3.1). The rate in Switzerland was also low. Rates in northern, western and southern European countries were lower than the EU average rate of 663. They were highest in Baltic and central European countries – Bulgaria, Latvia, Lithuania and Romania, for instance, had age-standardised rates almost twice those of the lowest countries at over 900 deaths per 100 000 population. Rates in Estonia, Hungary and the Slovak Republic were above 800. Male mortality rates were lowest in Malta, Sweden and Italy, and among other countries, in Iceland and Switzerland. They were high in Latvia and Lithuania. Female rates were low in France, Italy and Spain, as well as in Switzerland, and high in Bulgaria and Romania, along with the Former Yugoslav Republic of Macedonia. A significant gender gap exists in mortality rates (Figure 1.3.1). Across all EU member states, the male mortality rate was, on average, 70% higher than the female rate in 2010. But large differences exist among countries – in Estonia, Latvia and Lithuania, male rates were more than twice those of females, whereas in the Denmark, the Netherlands, Sweden and the United Kingdom, they were only around 40% higher. Lower mortality rates translate into higher life expectancies (see Indicator 1.1 “Life expectancy and healthy life expectancy at birth”). Differences in life expectancy among countries with the lowest and highest mortality rates are in the order of 8 years for females and 12 years for males. Some important causes of mortality that have been influenced through effective public health measures include ischemic heart disease, lung cancer, alcohol-

related mortality, suicide, transport accidents, cervical cancer and AIDS (Cayotte and Buchow, 2009). Although mortality rates in central Europe are still comparatively high, significant declines have occurred in a number of these countries since 1995 (Figures 1.3.2 and 1.3.3). Mortality rates in the Czech Republic, Estonia, Hungary, Poland and Slovenia have fallen by more than 25%, a decline that is greater than the EU average. Ireland has also seen a decline of close to 40%, driven largely by reductions in cardiovascular and respiratory diseases mortality, which in turn may be linked to rising living standards and increased expenditure on public and private health services in recent decades. In contrast, declines in the Slovak Republic, Bulgaria and Lithuania have been smaller. Declines in Belgium, Greece and Sweden have also been modest, although these countries began the period with rates that were already low. The leading causes of death in Europe include cardiovascular diseases (such as heart attack and stroke), and cancer. Deaths from these diseases, plus selected external causes of death (transport accidents and suicide), are examined more closely in the following four indicators.

Definition and comparability Mortality rates are based on numbers of deaths registered in a country in a year divided by the size of the corresponding population. The rates have been directly age-standardised to the WHO European standard population to remove variations arising from differences in age structures across countries and over time. The source is the Eurostat Statistics Database. Deaths from all causes are classified to ICD-10 Codes A00-Y89, excluding S00-T98. Mathers et al. (2005) have provided a general assessment of the coverage, completeness and reliability of data on causes of death.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.3. MORTALITY FROM ALL CAUSES

1.3.1. Mortality rates from all causes of death, 2010 (or nearest year) Males Total population

Females Males and females

Spain Italy France Malta Sweden Luxembourg Cyprus Netherlands Ireland United Kingdom Austria Germany Finland Greece Slovenia Belgium Portugal Denmark EU27 Czech Republic Poland Estonia Slovak Republic Hungary Latvia Romania Lithuania Bulgaria

488 496 510 517 520 525 532 543 545 554 563 565 574 577 601 601 602 644 663 724 776 840 855 898 951 959 964 970

391 376

537 794 965

1 200 900 600 Age-standardised rates per 100 000 population

300

626

430

628 679

434 416

656

424

659 660

454 450

655

468

718 697

442 453

755

429

693

474

801

449

765

474

783 772

460 541

866

509

940

557

1 065

557

1 246

577

1 151 1 208

640 673

1 362

682

1 237

733

1 418

660

1 251

747

Switzerland Iceland Norway Croatia FYR of Macedonia

490 507

642 632 679

362

394 422 441

614 604 657 1 029

616

1 127

823

500

1 000 1 500 Age-standardised rates per 100 000 population

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population.

1 2 http://dx.doi.org/10.1787/888932702993

1.3.2. Decline in mortality rates from all causes, 1995-2010 (or nearest year) Ireland Estonia Slovenia Portugal Malta Czech Republic Luxembourg United Kingdom Spain Poland Germany Italy Denmark Hungary Finland Netherlands EU25 Austria France Latvia Greece Sweden Belgium Lithuania Bulgaria Slovak Republic

1.3.3. Trends in mortality rates from all causes, selected EU member states, 1995-2010

Bulgaria

Ireland

Spain

EU25

Age-standardised rates per 100 000 population 1 400

33 31 30 29 28 27 27 27 26 26 26 26 26 25 25 24 23 23

1 200

1 000

800

20 20 19 19 17 16

Iceland Norway Switzerland

600 29 24 23

40 50 Percentage decline

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703012

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

400 1995

2000

2005

2010

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703031

1.4. MORTALITY FROM HEART DISEASE AND STROKE

Cardiovascular diseases are the main cause of mortality in almost all EU member states, accounting for 36% of all deaths in the region in 2010. They cover a range of diseases related to the circulatory system, including ischemic heart disease (known as IHD, or heart attack) and cerebro-vascular disease (or stroke). Together, IHD and stroke comprise 60% of all cardiovascular deaths, and caused more than one-fifth of all deaths in EU member states in 2010. Ischemic heart disease is caused by the accumulation of fatty deposits lining the inner wall of a coronary artery, restricting blood flow to the heart. IHD alone was responsible for 13% of all deaths in EU member states in 2010. Mortality from IHD varies considerably, however (Figure 1.4.1); Baltic countries report the highest IHD mortality rates, Lithuania for both males and females, followed by Latvia, the Slovak Republic and Estonia. IHD mortality rates are also relatively high in Finland and Malta, with rates several times higher than in France, Portugal, the Netherlands and Spain. There are regional patterns to the variability in IHD mortality rates. Besides the Netherlands and Luxembourg, the countries with the lowest IHD mortality rates are four countries located in Southern Europe: France, Italy, Portugal and Spain, with Cyprus and Greece also having low rates. This lends support to the commonly held hypothesis that there are underlying risk factors, such as diet, which explain differences in IHD mortality across countries. Death rates for IHD are much higher for men than for women in all countries (Figure 1.4.1). On average across EU member states, IHD mortality rates in 2010 were nearly two times greater for men. The disparity was greatest in Cyprus, France and Luxembourg, with male rates two-tothree times higher, and least in Malta, Romania and the Slovak Republic, at 60% higher. Since the mid-1990s, IHD mortality rates have declined in nearly all countries (Figure 1.4.3). The decline has been most remarkable in Denmark, Ireland, the Netherlands and the United Kingdom. Estonia and Norway also saw IHD mortality rates cut by one-half or more, although rates in Estonia are still high. Declining tobacco consumption contributed significantly to reducing the incidence of IHD, and consequently to reducing mortality rates. Improvements in medical care have also played a part [see Indicator 3.8 “Cardiac procedures (coronary angioplasty)”]. A small number of countries, however, have seen little or

no decline since 1995. Declines in Hungary, Poland and the Slovak Republic have been moderate, at under 20%. Stroke was the underlying cause for about 9% of all deaths in 2010. It is a loss of brain function caused by the disruption of the blood supply to the brain. In addition to being an important cause of mortality, the disability burden from stroke is substantial (Moon et al., 2003). As with IHD, there are large variations in stroke mortality rates across countries (Figure 1.4.2). Again, the rates are highest in Baltic and central European countries, including Bulgaria, Hungary, Latvia, Lithuania, Romania and the Slovak Republic. They are the lowest in Cyprus, France, Ireland and the Netherlands. Rates are also low in Switzerland, Iceland and Norway. Looking at trends over time, stroke mortality has decreased in all EU member states since 1995, with a more pronounced fall after 2003 (Figure 1.4.4). Rates have declined by around 60% in Austria, Estonia and Portugal. The decline has only been moderate in Lithuania, Poland and the Slovak Republic. As with IHD, the reduction in stroke mortality can be attributed at least partly to a reduction in risk factors. Tobacco smoking and hypertension are the main modifiable risk factors for stroke. Improvements in medical treatment for stroke have also increased survival rates (see Indicator 4.4 “In-hospital mortality following stroke”).

Definition and comparability Mortality rates are based on numbers of deaths registered in a country in a year divided by the size of the corresponding population. The rates have been directly age-standardised to the WHO European standard population to remove variations arising from differences in age structures across countries and over time. The source is the Eurostat Statistics Database. Deaths from ischemic heart disease are classified to ICD-10 Codes I20-I25, and stroke to I60-I69. Mathers et al. (2005) have provided a general assessment of the coverage, completeness and reliability of data on causes of death.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.4. MORTALITY FROM HEART DISEASE AND STROKE

1.4.1. Ischemic heart disease, mortality rates, 2010 (or nearest year) Males France Portugal Netherlands Spain Luxembourg Italy Denmark Belgium Slovenia Greece Cyprus Germany United Kingdom Sweden Ireland Austria Malta Poland Bulgaria EU27 Finland Czech Republic Romania Hungary Estonia Slovak Republic Latvia Lithuania

Females

Males

19 29

97 109

37 57

111

111 117

128

131

132

133

60 81

156

156 177

213

123

240

147

282

167

299

150

338

211

378

178

429

230

Norway Switzerland Iceland FYR of Macedonia Croatia

1.4.2. Stroke, mortality rates, 2010 (or nearest year)

118

119

100

200 300 400 500 Age-standardised rates per 100 000 population

Females

31 36

38 38

33 41

49 51

109

110

139

106

161

114

195

150

214

152

Switzerland Iceland Norway Croatia FYR of Macedonia

208

131

France Netherlands Cyprus Ireland Austria Spain Germany Malta United Kingdom Belgium Sweden Denmark Luxembourg Finland Italy Slovenia Greece EU27 Czech Republic Poland Portugal Estonia Slovak Republic Hungary Lithuania Latvia Romania Bulgaria

43 125

198

174

100 150 200 250 Age-standardised rates per 100 000 population

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703050

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703069

1.4.3. Trends in ischemic heart disease mortality rates, selected EU member states, 1995-2010

1.4.4. Trends in stroke mortality rates, selected EU member states, 1995-2010

Denmark

France

Lithuania

Bulgaria

Age-standardised rates per 100 000 population 500

400

200

300

150

200

100

0 1995

1997

1999

2001

Estonia

France

Age-standardised rates per 100 000 population 250

2003

2005

2007

2009

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703088

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

0 1995

1997

1999

2001

2003

2005

2007

2009

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703107

1.5. MORTALITY FROM CANCER

Cancer is the second leading cause of mortality in EU member states after diseases of the circulatory system, accounting for 28% of all deaths in 2010. In 2010, cancer mortality rates were the lowest in Cyprus, Finland and Sweden, as well as Switzerland, at under 150 deaths per 100 000 population. They were the highest in central European countries, including the Czech Republic, Hungary, Poland, the Slovak Republic and Slovenia, at close to or above 200 deaths per 100 000 population. Cancer mortality rates are higher for men than for women (Figure 1.5.1). In 2010, the gender gap was particularly wide in Estonia, Latvia, Lithuania, Portugal, the Slovak Republic and Spain, with mortality rates among men more than twice those for women. This gap can be explained partly by the greater prevalence of risk factors among men, as well as the lesser availability or use of screening programmes for cancers affecting men, leading to lower survival rates after diagnosis. Lung cancer still accounts for the greatest number of cancer deaths among men in EU member states, except in Sweden. Lung cancer is also one of the main causes of cancer mortality among women. Smoking is the most important risk factor for lung cancer. In 2010, death rates from lung cancer among men were the highest in Baltic and central European countries (Hungary, Latvia, Lithuania, Poland, as well as Croatia) (Figure 1.5.2). These are all countries where smoking rates among men are relatively high. Death rates from lung cancer among men are low in Nordic countries (Finland, Iceland, Norway and Sweden) as well as in Cyprus, countries with low smoking rates among men (see Indicator 2.5 “Smoking among adults”). Denmark and Iceland, however, have high rates of lung cancer mortality among women. Breast cancer is the most common form of cancer among women in all European countries (Ferlay et al., 2010). It accounted for around 30% of cancer incidence among women in 2008, and 18% of female cancer deaths in 2010. While there has been an increase in incidence rates of breast cancer over the past decade, death rates have declined or remained stable, indicating increases in survival rates due to earlier diagnosis and better treatment (see Indicator 4.8 “Screening, survival and mortality for breast cancer”). The lowest mortality rates from breast cancer are in Bulgaria, Portugal, Spain and Sweden, as well as Norway (below 20 deaths per 100 000 females), while the highest rates are in Belgium and Denmark (close to 30) (Figure 1.5.3). Prostate cancer has become the most commonly occurring cancer among men in many European countries,

particularly for those aged over 65 years of age, although death rates from prostate cancer remain lower than for lung cancer in all countries except Sweden. The rise in the reported incidence of prostate cancer in many countries during the 1990s and 2000s was largely due to the greater use of prostate-specific antigen (PSA) diagnostic tests. Death rates from prostate cancer in 2010 varied from lows of less than 15 per 100 000 males in Malta and Luxembourg – although annual numbers of deaths are small in these countries – to highs of more than 30 per 100 000 males in a range of central European and Nordic countries (Figure 1.5.4). The causes of prostate cancer are not well understood. Some evidence suggests that environmental and dietary factors might influence the risk of prostate cancer (Institute of Cancer Research, 2012). Death rates from all types of cancer for males and females have declined at least slightly in most member states since 1995, although the decline has been more modest than for cardiovascular diseases, explaining why cancer now accounts for a larger share of all deaths. The exceptions to this declining pattern are among Baltic and central European countries – Bulgaria, Latvia, Lithuania, Romania and the Former Yugoslav Republic of Macedonia – where cancer mortality has remained static or increased.

Definition and comparability Mortality rates are based on numbers of deaths registered in a country in a year divided by the size of the corresponding population. The rates have been directly age-standardised to the WHO European standard population to remove variations arising from differences in age structures across countries and over time. The source is the Eurostat Statistics Database. Deaths from all cancers are classified to ICD-10 Codes C00-C97, lung cancer to C32-C34, breast cancer to C50 and prostate cancer to C61. The international comparability of cancer mortality data can be affected by differences in medical training and practices as well as in death certification procedures across countries. Mathers et al. (2005) have provided a general assessment of the coverage, completeness and reliability of data on causes of death.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.5. MORTALITY FROM CANCER

1.5.1. All cancers mortality rates, males and females, 2010 (or nearest year) Males Cyprus Sweden Finland Malta Germany Ireland United Kingdom Austria Greece Luxembourg Bulgaria Italy Spain Denmark Portugal Netherlands Belgium France EU27 Romania Czech Republic Slovenia Poland Slovak Republic Estonia Latvia Lithuania Hungary

99 130 114 128 128 148 147 126 109 120 114 122 102 168 108 152 129 116 132 130 148 146 147 139 136 143 133

Females

248 263 270 271 284 286 288 293 333 186 187 191

134 117 133

228

128

298

153

Males

153 168 174 184 199 200 202 204 207 212 212 212 218 219 220 227 227 229 230

175

Iceland Switzerland Norway FYR of Macedonia Croatia

100

1.5.2. Lung cancer mortality rates, males and females, 2010 (or nearest year)

Sweden Cyprus Finland Ireland Austria United Kingdom Portugal Malta Germany Luxembourg Denmark Italy France EU27 Netherlands Spain Bulgaria Czech Republic Slovak Republic Slovenia Greece Estonia Romania Belgium Lithuania Latvia Poland Hungary

28 19 32 9 13 20 17 43

42 45 48 50 50 50 51 52 55 56 61 62 64 65 67 68 70 70 71 73

15 16 19 32 11 10 20 15 20 13 12 13 20 9 10

76 78 80 82 83 92

116

Iceland Norway Switzerland FYR of Macedonia Croatia

200 300 400 Age-standardised rates per 100 000 population

Females

23 10 15

44 45

25 19 13

76 88

50 75 100 125 Age-standardised rates per 100 000 population

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703126

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703145

1.5.3. Breast cancer mortality rates, females, 2010 (or nearest year)

1.5.4. Prostate cancer mortality rates, males, 2010 (or nearest year)

Spain Sweden Bulgaria Poland Portugal Czech Republic Greece Finland Cyprus Slovak Republic Estonia Romania Austria Italy EU27 France Germany Lithuania United Kingdom Slovenia Hungary Latvia Luxembourg Malta Ireland Netherlands Belgium Denmark

17.7 19.1 19.4 19.8 20.0 20.6 21.1 21.2 21.5 22.0 22.1 22.6 22.8 23.0 23.2 23.6 24.0 24.2 24.5 24.8 25.0 25.2 25.5 25.8 26.2 26.8 28.3 28.9

Norway Iceland Switzerland FYR of Macedonia Croatia

19.0 20.1 22.1 23.7 27.6

20 30 40 Age-standardised rates per 100 000 females

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703164

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

Malta Luxembourg Italy Romania Bulgaria Greece Spain Cyprus Germany France Austria Belgium Poland Hungary EU27 Czech Republic Finland Slovak Republic Portugal United Kingdom Netherlands Ireland Slovenia Lithuania Denmark Sweden Latvia Estonia

12.0 14.6 15.1 15.4 15.5 16.6 17.3 17.5 20.0 20.1 20.6 20.9 20.9 21.6 22.6 23.1 23.2 23.2 23.4 23.8 25.1 25.2 31.0 31.3 32.1 32.3 32.4 36.6

FYR of Macedonia Switzerland Croatia Iceland Norway

17.4 24.5 28.1 29.8 32.6

20 30 40 Age-standardised rates per 100 000 males

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703183

1.6. MORTALITY FROM TRANSPORT ACCIDENTS

Injuries from transport accidents â&#x20AC;&#x201C; most of which are due to road traffic â&#x20AC;&#x201C; are a major public health problem in the European Union, causing the premature deaths of some 40 000 people every year. In addition to these deaths, more than 1.5 million people are estimated to be so seriously injured as to require hospital admission each year (OECD/ITF, 2011a). Around 4 000-5 000 transport accident deaths occurred in each of France, Germany, Italy and Poland in 2010. Mortality from road accidents is the leading cause of death among children and young people, and especially young men, in many countries. Most fatal traffic injuries occur in passenger vehicles, although the fatality risk for motor cycles and scooters is highest among all modes of transport. The direct and indirect financial costs of transport accidents are substantial; one estimate put these at up to 3% of gross national product annually in highly-motorised countries (WHO, 2009a). Death rates were the highest in Romania, Greece and Lithuania in 2010, all in excess of 12 deaths per 100 000 population (Figure 1.6.1). They were the lowest in Malta, the Netherlands, Sweden and the United Kingdom, at less than four deaths per 100 000 population, much lower than the EU average of 7.7. A four-fold difference exists between the countries with the lowest and highest rates. In all EU member states, death rates from transport accidents are much higher for males than for females, with disparities ranging from three times higher in Denmark, Germany, Ireland, Luxembourg, and the Netherlands, to around five times higher in Cyprus and Greece. On average, around four times as many males than females die in transport accidents (Figure 1.6.1). Much transport accident injury and mortality is preventable. Road security has increased greatly over the past decades in many countries through improvements of road systems, education and prevention campaigns, the adoption of new laws and regulations and the enforcement of these laws through more traffic controls. As a result, death rates due to transport accidents have been more

than halved across the European Union since 1995 (Figures 1.6.2 and 1.6.3). Estonia and Luxembourg have seen the largest declines at 71% since 1995, with most of the fall in Estonia occurring in the mid-1990s. Reductions in Ireland, Portugal and Slovenia and a number of other countries are more than 60% since 1995, although vehicle kilometers travelled have increased substantially in the same period (OECD/ITF, 2011a). Death rates have also declined in Belgium, Greece and Bulgaria, but at a slower pace, and therefore remain well above the EU average. The effects of the economic crisis may have a favourable outcome on transport accident mortality. Many countries had a slight decrease or stagnation in traffic volumes since 2008, accompanied by a much more significant reduction in fatalities. However, in the long-term, effective road safety policies are the main contributor to reduced mortality (OECD/ITF, 2011b).

Definition and comparability Mortality rates are based on numbers of deaths registered in a country in a year divided by the size of the corresponding population. The rates have been directly age-standardised to the WHO European standard population to remove variations arising from differences in age structures across countries and over time. The source is the Eurostat Statistics Database. Deaths from transport accidents are classified to ICD-10 Codes V01-V99. The majority of deaths from transport accidents are due to road traffic accidents. Mortality rates from transport accidents in Luxembourg are biased upward because of the large volume of traffic in transit, resulting in a significant proportion of nonresidents killed. Mathers et al. (2005) have provided a general assessment of the coverage, completeness and reliability of data on causes of death.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

1.6. MORTALITY FROM TRANSPORT ACCIDENTS

1.6.1. Transport accident mortality rates, 2010 (or nearest year) Males Total population

Females Males and females

United Kingdom Malta Sweden Netherlands Ireland Germany Luxembourg Spain Denmark Finland Austria France Slovenia Italy EU27 Czech Republic Estonia Portugal Hungary Slovak Republic Bulgaria Belgium Cyprus Latvia Poland Lithuania Greece Romania

3.4 3.6 3.8 3.9 4.2 4.4 4.8 5.1 5.5 5.9 6.9 6.9 7.1 7.4 7.7 8.1 8.1 8.3 8.9 8.9 9.1 10.0 10.5 10.8 11.0 12.8 13.6 15.1

7.2 10.3

20 15 10 Age-standardised rates per 100 000 population

5.1

2.4

5.0 5.9 5.8

1.6 2.1

6.4

2.2

6.7 7.3

2.3 2.5

8.2

2.1

8.0

3.0 2.5

9.5

2.8

11.2

3.0 2.8

11.1 11.8

2.9

12.2

3.4 3.3

12.3 12.9 13.2

3.9 3.6 3.9

13.4 14.4

3.8

14.4 14.5 15.5

3.8 4.6 3.3

18.0 16.8 17.9

5.5 4.5 5.0

21.7 22.3

4.8

24.0

6.9

Iceland Switzerland Norway FYR of Macedonia Croatia

4.2 5.0 5.2

1.6

7.6 8.3

0.7 1.9

8.4

2.0

10.8

3.7 4.1

16.9

15 20 25 30 Age-standardised rates per 100 000 population

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population.

1 2 http://dx.doi.org/10.1787/888932703202

1.6.2. Trends in transport accident mortality rates, selected EU member states, 1995-2010 Greece

Slovenia

United Kingdom

EU25

Estonia Luxembourg Slovenia Portugal Ireland Spain Germany Latvia Hungary Denmark Netherlands Austria EU25 France Lithuania Poland Czech Republic Finland United Kingdom Italy Malta Slovak Republic Sweden Bulgaria Greece Belgium

Age-standardised rates per 100 000 population 25

0 1995

1.6.3. Decline in transport accident mortality rates, 1995-2010 (or nearest year) 71 71 66 66 65 64 62 61 52 51 51 51 51 50 48 48 47 45 44 44 44 43 41 39 37 36

Iceland Switzerland Norway 1997

1999

2001

2003

2005

2007

2009

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703221

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

71 50 38

80 100 Percentage decline

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703240

1.7. SUICIDE

The intentional killing of oneself can be seen as evidence not only of personal breakdown, but also of a deterioration of the social context in which an individual lives. Suicide may be the end-point of a number of different contributing factors. It is more likely to occur during crisis periods associated with upheavals in personal relationships, through alcohol and drug abuse, unemployment, clinical depression and other forms of mental illness. Because of this, suicide is often used as a proxy indicator of the mental health status of a population. However, the number of suicides in certain countries may be underreported because of the stigma that is associated with the act, or because of data issues associated with reporting criteria (see “Definition and comparability”). Suicide is a significant cause of death in many EU member states, with approximately 60 000 such deaths in 2010. Rates of suicide were low in southern European countries – Cyprus, Greece, Italy, Malta, Portugal and Spain – as well as in the United Kingdom, at eight deaths or less per 100 000 population (Figure 1.7.1). They were highest in the Baltic States and Central Europe; in Estonia, Hungary, Latvia, Lithuania and Slovenia there were more than 17 deaths per 100 000 population. There is more than a ten-fold difference between Lithuania and Greece, the countries with the lowest and highest death rates.

(Figure 1.7.3). The high suicide rates in Lithuania have been associated with a wide range of factors including rapid socio-economic transition, increasing psychological and social insecurity and the absence of a national suicide prevention strategy. Similarly in Hungary, societal factors including employment and socio-economic circumstances, as well as individual demographic and clinical factors have been cited as determinants of suicide (Almasi et al., 2009). Mental health problems are rising in the European Union. The European Pact for Mental Health and Wellbeing, launched in 2008, recognised the prevention of depression and suicide as one of five priority areas. It called for action through improved training of mental health professionals, restricted access to potential means for suicide, measures to raise mental health awareness, measures to reduce risk factors for suicide such as excessive drinking, drug abuse and social exclusion, depression and stress, and provision of support mechanisms after suicide attempts and for those bereaved by suicide, such as emotional support helplines (EC, 2009b).

Definition and comparability

Death rates from suicide are four-to-five times greater for men than for women across the European Union, although in those countries with the highest rates, male deaths are up to seven times as common (Figure 1.7.1). The gender gap is narrower for attempted suicides, reflecting the fact that women tend to use less fatal methods than men. Suicide is also related to age, with young people aged under 25 and elderly people especially at risk. While suicide rates among the latter have generally declined over the past two decades, little progress has been observed among younger people.

The World Health Organization defines “suicide” as an act deliberately initiated and performed by a person in the full knowledge or expectation of its fatal outcome. Comparability of suicide data between countries is affected by a number of reporting criteria, including how a person’s intention of killing themselves is ascertained, who is responsible for completing the death certificate, whether a forensic investigation is carried out, and the provisions for confidentiality of the cause of death. Caution is required therefore in interpreting variations across countries.

Since 1995, suicide rates have decreased in many countries, with pronounced declines of 40% or more in Bulgaria, Estonia and Latvia (Figure 1.7.2). Despite this progress, Estonia and Latvia still have among the highest suicide rates in Europe. On the other hand, death rates from suicides have increased since 1995 in Malta, Poland and Portugal, as well as Iceland, although rates in Iceland and Malta are dependent on small numbers. Iceland, Malta and Portugal still remain below the EU average. There is no strong evidence that national suicide rates have increased since the onset of the economic crisis.

Mortality rates are based on numbers of deaths registered in a country in a year divided by the size of the corresponding population. The rates have been directly age-standardised to the WHO European standard population to remove variations arising from differences in age structures across countries and over time. The source is the Eurostat Statistics Database.

Suic ide rate s in Lithu ania increas ed s te adily after 1990, especially among young men, peaking in 1996

Deaths from suicide are classified to ICD-10 Codes X60-X84. Mathers et al. (2005) have provided a general assessment of the coverage, completeness and reliability of data on causes of death.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.7. SUICIDE

1.7.1. Suicide mortality rates, 2010 (or nearest year) Males

Females

Total population

Males and females Greece Cyprus Italy Spain United Kingdom Malta Portugal Netherlands Bulgaria Luxembourg Denmark Germany Slovak Republic Ireland Romania EU27 Sweden Austria Czech Republic France Poland Belgium Finland Slovenia Estonia Latvia Hungary Lithuania

3.0 3.6 5.4 5.8 6.4 7.4 8.2 8.8 9.3 9.7 9.9 9.9 10.8 11.1 11.2 12.3 12.3 12.8 12.8 14.9 15.4 16.8 16.8 17.2 18.3 20.7 21.7 31.5

11.5 14.7 15.1

35 30 25 20 15 Age-standardised rates per 100 000 population

5.9

1.3

8.8

2.3

9.4

2.5

10.1

2.9 0.7

14.1 13.5

3.8

12.7

5.2

15.3

4.0

15.8

4.0 4.3

15.8

4.7

15.6 19.4

3.0

17.7

4.5

19.9

3.2

20.7

4.7 17.7

7.1

20.9

5.7

22.1

4.1

23.3

7.4

28.0

3.8 25.0

9.1

25.7

8.1

29.3

6.1

33.9

5.3

37.6

6.7

37.4

8.5

58.5

8.8

FYR of Macedonia Iceland Norway Croatia Switzerland

8.0 11.5

5.2

0.9

12.6

3.9

18.3 16.5

4.6 6.5

24.3

6.6 21.8

9.1

30 40 50 60 Age-standardised rates per 100 000 population

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population.

1 2 http://dx.doi.org/10.1787/888932703259

1.7.2. Change in suicide rates, 1995-2010 (or nearest year) Estonia Latvia Bulgaria Denmark Slovenia Austria Finland Lithuania Luxembourg EU25 Hungary Germany Italy France Czech Republic Spain Slovak Republic Belgium Sweden United Kingdom Greece Netherlands Ireland Poland Portugal Malta

1.7.3. Trends in suicide rates, selected European countries, 1995-2010

-55

Estonia

-44 -40 -38 -37 -37 -36 -34 -32 -31 -29 -29

Greece

Lithuania

EU25

Age-standardised rates per 100 000 population 50

-22 -21 -20 -19 -16 -15 -13

-9 -6 -4 -3 5 9 61

Switzerland Norway Iceland

-18 -3 10

-80

-40

40 80 Percentage change

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703278

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

0 1995

2000

2005

2010

Source: Eurostat Statistics Database. Data are age-standardised to the WHO European standard population. 1 2 http://dx.doi.org/10.1787/888932703297

1.8. INFANT MORTALITY

Infant mortality, the rate at which babies and children of less than one year of age die, reflects the effect of economic and social conditions on the health of mothers and newborns, as well as the effectiveness of health systems. In most European countries, infant mortality is low and there is little difference in rates (Figure 1.8.1). A small group of countries, however, have infant mortality rates above five deaths per 1 000 live births. In 2010, rates ranged from a low of less than three deaths per 1 000 live births in Nordic countries (with the exception of Denmark), Portugal, Slovenia and the Czech Republic, up to a high of 9.8 and 9.4 in Romania and Bulgaria respectively, and 13.6 in Turkey. Infant mortality rates were also relatively high (more than six deaths per 1 000 live births) in Serbia and the Former Yugoslav Republic of Macedonia. The average across the 27 EU member states in 2010 was 4.2 deaths per 1 000 live births. Infant mortality rates tend to be higher than the EU average in central European countries, with the exceptions of the Czech Republic and Slovenia, both of which have had consistently lower rates. Around two-thirds of the deaths that occur during the first year of life are neonatal deaths (i.e. during the first four weeks). Birth defects, prematurity and other conditions arising during pregnancy are the principal factors contributing to neonatal mortality in developed countries. With an increasing number of women deferring childbearing and the rise in multiple births linked with fertility treatments, the number of pre-term births has tended to increase (see Indicator 1.9 “Infant health: Low birth weight”). In a number of higher-income countries, this has contributed to a leveling-off of the downward trend in infant mortality rates over the past few years. For deaths beyond one month (post neonatal mortality), there tends to be a greater range of causes – the most common being SIDS (Sudden Infant Death Syndrome), birth defects, infections and accidents. All European countries have achieved remarkable progress in reducing infant mortality rates from the levels of 1970, when the average was 25 deaths per 1 000 live births, to the current average of 4.2 (Figure 1.8.1). This equates to a cumulative reduction of over 80% since 1970. Portugal has seen its infant mortality rate reduced by 7.5% per year on average since 1970, moving from the country

with the highest rate in Europe to an infant mortality rate among the lowest in Europe in 2010 (Figure 1.8.2). Large reductions in infant mortality rates have also been observed in Slovenia, Italy, Cyprus and Greece, as well as the Former Yugoslav Republic of Macedonia and Croatia. The reduction in infant mortality rates has been slower in Bulgaria, Latvia and the Netherlands, although rates in the latter two countries were low in 1970. Infant mortality rates in Poland declined rapidly in the early 1990s to approach the EU average. Numerous studies have used infant mortality rates as a health outcome to examine the effect of a variety of medical and non-medical determinants of health (e.g. OECD, 2010a). Although most analyses show an overall negative relationship between infant mortality and health spending, the fact that some countries with a high level of health expenditure do not exhibit low levels of infant mortality suggests that more health spending is not necessarily required to obtain better results (Retzlaff-Roberts et al., 2004). A body of research also suggests that many factors beyond the quality and efficiency of the health system – such as income inequality, the social environment, and individual lifestyles and attitudes – influence infant mortality rates (Schell et al., 2007).

Definition and comparability The infant mortality rate is the number of deaths of children under one year of age in a given year, expressed per 1 000 live births. Neonatal mortality refers to the death of children under 28 days. Some of the international variation in infant and neonatal mortality rates may be due to variations among countries in registering practices of premature infants. Most countries have no gestational age or weight limits for mortality registration. Minimal limits exist for Norway (to be counted as a death following a live birth, the gestational age must exceed 12 weeks) and in the Czech Republic, the Netherlands and Poland a minimum gestational age of 22 weeks and/or a weight threshold of 500 grams is applied.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.8. INFANT MORTALITY

1.8.1. Infant mortality rates, 2010 and decline 1970-2010 2010 (or nearest year)

Decline 1970-2010 (or nearest year) Finland Portugal Slovenia Sweden Czech Republic Spain Cyprus Estonia Denmark Germany Italy Luxembourg France Belgium Greece Ireland Netherlands Austria EU27 Lithuania United Kingdom Poland Hungary Malta Latvia Slovak Republic Bulgaria Romania

2.3 2.5 2.5 2.5 2.7 3.2 3.3 3.3 3.4 3.4 3.4 3.4 3.5 3.6 3.8 3.8 3.8 3.9 4.2 4.3 4.3 5.0 5.3 5.5 5.7 5.7 9.4 9.8

7.5 5.5 3.6 4.9 4.6 5.0 4.1 3.5 4.6 5.3 4.9 4.0 4.3 5.0 4.0 3.0 4.6 4.3 3.7 3.6 4.8 4.7 4.0 2.8 3.7 2.6 4.0

Iceland Norway Switzerland Croatia Montenegro Serbia FYR of Macedonia Turkey

2.2 2.8 3.8 4.4 5.7 6.7 7.6 13.6

15 10 Deaths per 1 000 live births

4.3

4.4 3.4 3.4 5.0 n.a. n.a. 5.9 n.a.

6 8 Average annual rate of decline (%)

Source: Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932703316

1.8.2. Infant mortality rates, selected European countries, 1970-2010 Finland

Portugal

Slovenia

EU27

Deaths per 1 000 live births 60

0 1970

1975

1980

1985

1990

1995

2000

2005

2010

Source: Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932703335

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

1.9. INFANT HEALTH: LOW BIRTH WEIGHT

Low birth weight – defined as a newborn weighing less than 2 500 grams – is an important indicator of infant health because of the close relationship between birth weight and infant morbidity and mortality. There are two categories of low birth weight babies: those occurring as a result of restricted foetal growth and those resulting from pre-term birth. Low birth weight infants have a greater risk of poor health or death, require a longer period of hospitalisation after birth, and are more likely to develop significant disabilities (UNICEF and WHO, 2004). Risk factors for low birth weight include adolescent motherhood, a previous history of low weight births, engaging in harmful behaviours such as smoking and excessive alcohol consumption, having poor nutrition, a background of low parental socio-economic status, and having had in-vitro fertilisation treatment. One-in-fifteen babies born in the European Union in 2010 – or 6.9% of all births – weighed less than 2 500 grams at birth. A north-south gradient is evident for low birth weight in Europe, in that the Nordic countries and Baltic States – including Estonia, Finland, Iceland, Latvia, Lithuania and Sweden – reported the smallest proportions of low weight births, with less than 5.0% of live births so defined. Countries from Southern Europe including Cyprus, Greece, Portugal and Spain, as well as Bulgaria, Hungary, Romania, Turkey and the Former Yugoslav Republic of Macedonia, are at the other end of the scale with rates of low birth weight infants above 7.5%. The proportion of low birth weight among European countries varies by a factor of almost three (Figure 1.9.1). Since 1980, and more so after 1995, the prevalence of low birth weight infants has increased in most European countries (Figure 1.9.1). There are several reasons for this rise. The number of multiple births, with the increased risks of pre-term births and low birth weight, has risen steadily, partly as a result of the rise in fertility treatments. Other factors which may have influenced the rise in low birth weight are older age at childbearing and increases in the use of delivery management techniques such as induction of labour and caesarean delivery, which have increased the survival rates of low birth weight babies. Greece, Malta, Portugal and Spain have seen great increases in the past three decades (Figure 1.9.2). As a result, the proportion of low birth weight babies in these countries is now above the European average. Low birth

weight proportions in Poland and Hungary have declined over the same time period. Little change occurred in Nordic countries including Denmark, Finland, Iceland and Sweden, although a rise was observed in Norway. Figure 1.9.3 shows some correlation between the percentage of low birth weight infants and infant mortality rates. In general, countries reporting a low proportion of low birth weight infants also report relatively low infant mortality rates. This is the case for instance for the Nordic countries. Greece, however, is an exception, reporting a high proportion of low birth weight infants but a low infant mortality rate. Despite the widespread use of a 2 500 grams limit for low birthweight, physiological variations in size occur among different countries and population groups, and these need to be taken into account when interpreting differences (EURO-PERISTAT, 2008). Some populations may have lower than average birth weights than others because of genetic differences. Comparisons of different population groups within countries show that the proportion of low birth weight infants is also influenced by non-medical factors. In England and Wales, mothers’ marital status at birth, being a mother from non-White ethnic group and living in a deprived area were associated with low birthweight (Bakeo and Clarke, 2006). In Greece, marital status, education, maternal occupation and region of residence were significant factors (Lekea-Karanika et al., 1999).

Definition and comparability Low birth weight is defined by the World Health Organization (WHO) as the weight of an infant at birth of less than 2 500 grams (5.5 pounds), irrespective of the gestational age of the infant. This is based on epidemiological observations regarding the increased risk of death to the infant and serves for international comparative health statistics. The number of low weight births is then expressed as a percentage of total live births. The majority of the data comes from birth registers. A small number of countries supply data for selected regions or from surveys.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.9. INFANT HEALTH: LOW BIRTH WEIGHT

1.9.1. Low birth weight infants, 2010 and change 1980-2010 2010 (or nearest year)

Change 1980-2010 (or nearest year) Estonia Sweden Finland Lithuania Latvia Ireland Denmark Poland Slovenia France Netherlands Luxembourg EU27 Belgium Germany United Kingdom Austria Italy Malta Czech Republic Spain Romania Portugal Hungary Slovak Republic Bulgaria Greece Cyprus

4.0 4.2 4.3 4.7 4.9 5.0 5.2 6.0 6.2 6.4 6.5 6.7 6.9 6.9 6.9 6.9 7.0 7.0 7.3 7.7 7.7 8.0 8.2 8.6 9.0 9.1 10.0 11.7

0.0 10.3 n.a. n.a. 25.0 -11.2 -21.1 6.9 23.1 62.5 6.3 21.7 23.2 25.5 3.0 22.8 25.0 73.8 30.5 108.4 5.7 78.3 -17.3 52.2 49.2 69.5 n.a.

Iceland Croatia Montenegro Norway Serbia Switzerland FYR of Macedonia Turkey

3.6 4.5 5.2 5.4 5.7 6.6 7.8 11.0

15 10 Percentage of newborns weighing less than 2 500 g

n.a.

5.9 n.a. n.a. 42.1 n.a. 29.4 n.a. n.a.

-50

100 150 % change over period

Source: OECD Health Data 2012; WHO European Health for All Database.

1 2 http://dx.doi.org/10.1787/888932703354

1.9.2. Trends in low birth weight infants, selected European countries, 1980-2010 Finland

Greece

Spain

1.9.3. Low birth weight and infant mortality, 2010 (or nearest year) EU27 Infant mortality (deaths per 1 000 live births) 15

Percentage of newborns weighing less than 2 500 g 12

TUR

R 2 = 0.20 10

ROU

2 1980

BGR

MKD SRB MLT GBR LVA MNE NLD SVK CHE LTU POL HUN AUT HRV IRL BEL DNK EST SWE ITA ESP PRT FIN NOR ISL CZE SVN LUX DEU FRA

GRC

CYP

0 1985

1990

1995

2000

2005

2010

Source: OECD Health Data 2012; WHO European Health for All Database. 1 2 http://dx.doi.org/10.1787/888932703373

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

10 12 Low birth weight (%)

Source: OECD Health Data 2012; WHO European Health for All Database. 1 2 http://dx.doi.org/10.1787/888932703392

1.10. SELF-REPORTED HEALTH AND DISABILITY

Most European countries conduct regular health surveys which allow respondents to report on different aspects of their health. A commonly-asked question relates to self-perceived health status, of the type: “How is your health in general?”. Despite the subjective nature of this question, indicators of perceived general health have been found to be a good predictor of people’s future health care use and mortality (DeSalvo et al., 2005; Bond et al., 2006). For the purpose of international comparisons however, cross-country differences in perceived health status are difficult to interpret because responses may be affected by social and cultural factors. Since they rely on the subjective views of the respondents, self-reported health status may reflect cultural biases or other influences. Also, since the elderly report poor health more often than younger people, countries with a larger proportion of aged persons will also have a lower proportion of people reporting good or very good health. In addition, the institutionalised population, which has poorer health than the rest of the population, is often not surveyed. With these limitations in mind, in almost all European countries a majority of the adult population rate their health as good or very good (Figure 1.10.1). In Ireland and Sweden, as well as Switzerland, more than eight out of ten people report good or very good health. Across the European Union, two-thirds (67%) of all adults rated their health as good or better, with France, Germany and Italy close to this average. Adults in central European countries, along with Portugal, report the lowest rates of good or very good health. In Croatia, Estonia, Hungary, Latvia, Lithuania, Poland and Portugal, less than 60% of all adults consider themselves to be in good health. These differences, however, do not necessarily mean that the general health of people in Ireland or Sweden is objectively better than that of citizens in Latvia or Portugal (Baert and de Norre, 2009). In all European countries, men are more likely than women to rate their health as good or better, with the largest differences in Portugal and Bulgaria. Unsurprisingly, people’s rating of their own health tends to decline with age. In many countries there is a particularly marked decline in a positive rating of one’s own health after age 45 and a further decline after age 65. People who are unemployed, retired or inactive more often report bad or very bad health (Baert and de Norre, 2009). People with a lower level of education or income do not rate their health as positively as people with higher levels (OECD, 2012a; Mackenbach et al., 2008). Another common health interview survey question asks whether respondents had any long-standing illnesses or health problems. Three-in-ten adults in EU member states reported having illnesses or health problems

(Figure 1.10.1). Adults in Finland and Estonia were more likely to report having illnesses or health problems, while these conditions were less commonly reported in Romania and Bulgaria. Women reported long-standing illnesses or health problems more often than men (an average of 33% vs. 28% across EU member states), with the gender divide greatest in Finland and Latvia. Reporting increased with age, from an average of 7% of young people aged 16-24 years, to 73% of older persons aged 85 years or more. There is a moderate negative association between adults reporting good/very good health, and reporting a longstanding illness or health problem (R2 = –0.28). When adults were asked whether they had been limited in their usual daily activities because of a health problem – which is one definition of disability – 24% answered that they had, with 8% of respondents “strongly limited” and 17% “limited to some extent” (Figure 1.10.2). Adults most commonly reported activity limitation in Estonia, Finland, Germany, Latvia, Portugal, Slovenia and the Slovak Republic, as well as Croatia (30% or more of respondents), and less so in Malta and Sweden (less than 15%). Severe activity limitation was more prevalent in Germany, Slovenia and the Slovak Republic, as well as Croatia (10% or more of respondents), and less so in Bulgaria and Malta (less than 5%). Adults with activity limitations were also less likely to report good or very good health (R2 = 0.53).

Definition and comparability Self-reported health reflects people’s overall perceptions of their own health, including both physical and psychological dimensions. Typically ascertained through health interview surveys, respondents are asked a number of questions on their health and functioning. The three questions used in the EU-SILC survey, and some other national surveys are: i) “How is your health in general? Is it very good, good, fair, bad, very bad”; ii) “Do you have any longstanding illness or health problem which has lasted, or is expected to last for six months or more?”; and iii) “For at least the past six months, have you been hampered because of a health problem in activities people usually do? Yes, strongly limited/Yes, limited/No, not limited”. Persons in institutions are not surveyed. Caution is required in making cross-country comparisons of perceived general health, since people’s assessment of their health is subjective and can be affected by their social and cultural backgrounds.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.10. SELF-REPORTED HEALTH AND DISABILITY

1.10.1. Adults’ self-reported health status, 2010 Good or very good health

Long-standing illness or health problem Ireland Sweden United Kingdom Netherlands Cyprus Greece Luxembourg Belgium Spain Denmark Romania Austria Finland Malta France Bulgaria EU27 Italy Germany Slovak Republic Czech Republic Slovenia Poland Hungary Estonia Lithuania Portugal Latvia

83 80 79 78 76 76 75 73 72 71 71 70 69 68 67 67 67 67 65 63 62 60 58 55 53 52 49 49

78 77 66 46

31 35 33 33 21 22 26 28 27 19 35 44 28 37 19 30 22 36 30 29 36 33 36 43 27 30 34

Switzerland Iceland Norway Turkey Croatia

100 90 80 70 % of population aged 16 and over

34 29 34 n.a. 37

40 50 % of population aged 16 and over

Source: EU Statistics on Income and Living Conditions survey; OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932703411

1.10.2. Adults reporting a limitation in usual activities, 2010 Limited strongly

Limited to some extent

11.7

12.1

23.7 17.2

9.6

5.7

23.6

23.5

22.9

23.3

22.4

20.0

5.9

10.2 21.6

10.5

9.4

8.3

7.1

7.9

8.7

9.4 19.0

21.9 18.8 15.8

17.6

16.2

15.1

6.9

10.5

12.0

12.6

22.1

7.0

7.9

9.6

7.5

17.0

7.9 16.0

16.9

7.9

5.6

15.5

6.0

6.6

6.2 14.3

9.2

6.0

8.2 10.8

8.4

11.7

10 8.9

14.0

7.3

3.8

6.1

3.8

5.2

11.2

5.5

% of population aged 16 and over 40

ay S w el an it z d er la nd Cr oa tia

M al Sw ta ed e Bu n lg ar ia Ir e la nd Cy pr us Gr Lu ee xe c m e bo ur g Un i te It a d l Ki y ng d L i om Cz t e c hu a n h Re i a pu bl ic Sp ai Be n lg iu m Po la nd EU De 2 7 nm ar k Fr an c Ro e Ne man i th er a la nd Au s st r Hu i a ng ar Es y to ni a La tv ia Fi nl a Po nd r tu g Sl Ge a l r ov ak man Re y pu b Sl lic ov en ia

Source: EU Statistics on Income and Living Conditions survey.

1 2 http://dx.doi.org/10.1787/888932703430

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.11. INCIDENCE OF SELECTED COMMUNICABLE DISEASES

Communicable diseases such as chlamydia, pertussis and hepatitis B still pose major threats to the health of European citizens. Chlamydia is the most common sexually transmitted infection in Europe. Three-quarters of all cases are reported among young people aged 15-24 years, and numbers are steadily increasing. It can be controlled through prevention, reducing risk behaviour, early detection and effective management. Pertussis (or whooping cough) is highly infectious, and is caused by the bacterium Bordetella pertussis. The disease derives its name from the sound made from the intake of air after a cough. Hepatitis B is an infection of the liver caused by the hepatitis B virus. The virus is transmitted by contact with blood or body fluids of an infected person. A small proportion of infections become chronic, and these people are at high risk of death from cancer or cirrhosis of the liver. Protection against pertussis and hepatitis B is available through vaccination (see Indicator 4.10 “Childhood vaccination programmes”). Over 285 000 chlamydia cases were reported annually in EU member states during 2007-09, with almost all infections reported by five countries (the United Kingdom, and the Nordic countries of Denmark, Finland, Norway and Sweden). The true number of chlamydia cases is likely to be much higher, since the infection is liable to underreporting and asymptomatic disease. Confirmed case rates were highest in Iceland (655 per 100 000 population), Denmark (514), Sweden (458), the United Kingdom (290) and Finland (258) (Figure 1.11.1). Between 2006 and 2009, incidence of reported and confirmed cases increased by 42%, although much of this was a result of improved case detection in a number of countries (ECDC, 2011). Over 14 000 pertussis cases were reported annually among EU member states in 2007-09, with an overall incidence of 5 per 100 000 population (Figure 1.11.2). The highest incidences were reported in Norway (104 cases per 100 000 population), the Netherlands (44), Estonia (38) and Slovenia (17). Most cases were reported from the Netherlands, Norway and Poland, which together contributed almost three-quarters (71%) of all cases reported in 2009. Pertussis incidence has more than halved since 1991-93, when the average rate among EU member states was 11.3 notified cases per 100 000 population. Two-thirds of all pertussis cases in 2008 occurred among children aged 5-14 years of age, although the disease may be underdiagnosed in adolescents and adults. The highest incidence occurred among infants aged less than one year, many of whom are too young to be vaccinated, and children aged 10-14 years, who may have not

had a full course of vaccination, or who may have lost their immunity. Vaccination status was known in only half of all reported cases, but of these 21% were unvaccinated (EUVAC.NET, 2010). Around 6 000 hepatitis B cases were reported annually in EU member states during 2007-09. The highest incidence rates occurred among Iceland (13.8 notified cases per 100 000 population, including both acute and chronic cases), Bulgaria (8.2) and Latvia (6.3) (Figure 1.11.3). The EU average was 2.0 cases per 100 000 population. The notification rate has declined since 1991-93, when it was 8.3 cases per 100 000 population on average. Hepatitis B infection is more common in the southern parts of Eastern and Central Europe, and low in prevalence in most of Western Europe. Around twice as many cases of hepatitis B occurred among males than females in 2009, with the majority reported in the age group 25-44 years (49% of the total), followed by 15-24 year-olds. The disease has the characteristics of both a sexually transmitted and a blood-borne disease, although the disease pattern and risk groups differ widely across Europe (ECDC, 2011). Enhanced surveillance systems will provide the better information which is needed to monitor the disease. The European Centre for Disease Prevention and Control (ECDC) was set up in 2005 to assist the European Union by identifying and assessing the risk of current and emerging threats to human health posed by infectious diseases.

Definition and comparability Although notification of chlamydia is compulsory in most European countries, national surveillance systems for sexually transmitted infections consist of voluntary, sentinel or laboratory systems, and often do not provide full country coverage. Countries also differ in reporting systems, diagnosis, testing and screening programmes. Underreporting is likely. Mandatory notification systems for pertussis and hepatitis B also exist in most European countries, although again case definitions, laboratory confirmation requirements and reporting systems may differ. Pertussis notification was voluntary in Belgium and France, and France had a sentinel surveillance system.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.11. INCIDENCE OF SELECTED COMMUNICABLE DISEASES

1.11.1. Notification rate of chlamydia infection, 2007-09 Denmark

1.11.2. Notification rate of pertussis, 2007-09 Netherlands

514

Sweden United Kingdom Finland

258

6.1

EU26

5.4

Sweden

5.2

Poland

4.7

Netherlands

Latvia

Lithuania

3.0

Slovak Republic

2.5

Bulgaria

2.2

Denmark

1.8

Belgium

1.7

Ireland

1.4

Belgium Malta Lithuania

Austria

7.9

Czech Republic

116

EU21

17.2

Finland

166

Ireland

37.9

Slovenia

290

Estonia

43.5

Estonia

458

Austria

1.3

United Kingdom

1.1

Slovenia

Italy

1.0

Hungary

Cyprus

0.7

Slovak Republic

Luxembourg

0.5

Poland

Greece

Spain

Portugal

0.5

Latvia

0.4

Hungary

0.4

Spain

0.3 0.1

Romania

France

Luxembourg

Greece

0.1

Cyprus

Romania

0.0

Malta

0.0

Iceland

655

Norway

483

200

400

103.5

Iceland

600 800 Per 100 000 population

0.0

Source: ECDC (2011).

100 125 Per 100 000 population

Source: ECDC (2011).

1 2 http://dx.doi.org/10.1787/888932703449

1 2 http://dx.doi.org/10.1787/888932703468

1.11.3. Notification rate of hepatitis B, 2007-09 Per 100 000 population 15 13.8

8.2

6.3

6 3.8

3.7

3.5

3.1

2.7

2.3

2.2

2.0

1.8

1.6

1.5

2.0

1.5

1.3

1.2

1.1

1.0

0.8

0.7

0.6

0.5

0.2

d an

ria

r tu

ce ee

y Fi

ar ng

al M

i te

us pr

ia th

en ov

n ai

It a

nd la

Ir e

a ni

bl pu

th Sl

Re h

ec Cz

ur bo

nm Lu

tv La

Source: ECDC (2011).

1 2 http://dx.doi.org/10.1787/888932703487

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

1.12. HIV/AIDS

The first cases of Acquired Immunodeficiency Syndrome (AIDS) were diagnosed more than 30 years ago. The onset of AIDS is caused as a result of HIV (human immunodeficiency virus) infection and can manifest itself as any number of different diseases, such as pneumonia and tuberculosis, as the immune system is no longer able to defend the body, leaving it susceptible to opportunistic infections and tumors. There is a time lag between HIV infection, AIDS diagnosis and death, which can be any number of years depending on the treatment administered. Despite worldwide research, there is no cure currently available. HIV remains a major public health issue in Europe, with continuing transmission. In 2010, almost 27 000 cases of newly diagnosed HIV infection were reported by EU member states, and another 1 600 cases in the six EU candidate countries, Norway and Switzerland. Estonia had the highest rate of new cases, at 27.8 per 100 000 population, followed by Belgium, Latvia and the United Kingdom, all at over ten (Figure 1.12.1). On average across EU member states, 6.2 new cases of HIV infection were diagnosed per 100 000 population in 2010. One quarter of cases were female, although the ratio varied greatly between countries, from Hungary (16 male cases for each female case) to Sweden (two). Approximately 800 000 persons were living with HIV infection in the European Union in 2010. The predominant mode of transmission of HIV was through men having sex with men (38%), followed by heterosexual contact (24%). However, in certain countries injecting drug use is also a common mode. Approximately 75% of heterosexually acquired HIV infection in Western and Central Europe is among migrants. The number of newly reported cases of AIDS in EU member states in 2010 was 4 643, representing an average incidence rate of 1.1 per 100 000 population (Figure 1.12.1). Following the first reporting of AIDS in the early 1980s, the number of cases rose rapidly to reach an average of almost four new cases per 100 000 population across EU member states at its peak in the middle of the 1990s, four times the current incidence rate. Public awareness campaigns contributed to steady declines in reported cases through the second half of the 1990s. In addition, the development and greater availability of antiretroviral drugs, which reduce or slow down the development of the disease, led to a sharp decrease in incidence from 1996 onward. The highest AIDS incidence rates among EU member states in 2010 were reported in Latvia, followed by Portugal and Spain, at two or more cases per 100 000 population.

Spain had the highest incidence rates in the first decade following the outbreak, although there was a sharp decline from 1994 onwards. Incidence rates in Portugal peaked somewhat later, towards the end of the 1990s. AIDS incidence rates in Latvia increased rapidly to the mid-2000s (Figure 1.12.2). Central European countries such as Bulgaria, the Czech and Slovak Republics, Hungary, Poland and Slovenia report the lowest incidence rates of AIDS, although incomplete reporting may lead to underestimates (ECDC and WHO Regional Office for Europe, 2011). In recent years, the number of AIDS cases reported in the EU has steadily declined. However, continuing transmission of HIV and increases in reported rates in some countries reinforce the need for evidence-based interventions which are adapted to the situation of each country. A European Commission Communication details the policy priorities regarding HIV in Europe for 2009-13. The main objectives are to reduce new HIV infections across all European countries by 2013; improve access to prevention, treatment, care and support; and to improve the quality of life of people affected by HIV/AIDS in the European Union and neighbouring countries. The Communication also highlights priority regions and priority groups and emphasises the improvement of knowledge, including surveillance, monitoring, evaluation and research (ECDC, 2012).

Definition and comparability The incidence rates of HIV (human immunodeficiency virus) and AIDS (acquired immunodeficiency s y nd ro m e) a re t h e nu m b er o f n ew ca s e s p er 100 000 population at year of diagnosis. However, since newly reported HIV diagnoses may also include persons infected several years ago, the data do not represent real incidence. Underreporting and underdiagnosis also affect incidence rates, and could be as much as 40% in some countries (ECDC, 2011). Note that data for recent years are provisional due to reporting delays, which can sometimes be for several years. Reporting is voluntary in some countries. Others report regional data only.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

1.12. HIV/AIDS

1.12.1. HIV and AIDS incidence rates in 2010 HIV incidence

AIDS incidence Estonia Latvia Belgium United Kingdom Portugal Spain Luxembourg Ireland EU27 France Netherlands Italy Sweden Cyprus Denmark Greece Lithuania Malta Finland Germany Poland Bulgaria Hungary Czech Republic Slovenia Romania Slovak Republic Austria

27.8 12.2 11.0 10.7 8.9 8.9 8.8 7.4 6.2 6.1 6.0 5.9 5.2 5.1 5.0 4.7 4.6 4.1 3.6 3.6 2.4 2.2 1.8 1.7 1.7 0.7 0.5 n.a.

7.6 5.3 2.3 2.0 1.5 0.7 0.2

5.5 0.7 1.0 3.3 2.0 0.8 0.9 1.1 1.0 1.4 1.2 0.7 1.2 0.8 0.8 1.0 1.4 0.6 0.3 0.4 0.4 0.3 0.2 0.3 0.7 0.0 0.6

Switzerland Iceland Norway Montenegro Serbia Croatia Turkey FYR of Macedonia

7.8

30 20 New cases per 100 000 population

1.9

1.9 0.3 0.5 1.0 0.6 0.4 0.1 0.4

4 6 New cases per 100 000 population

Source: ECDC and WHO Regional Office for Europe (2011).

1 2 http://dx.doi.org/10.1787/888932703506

1.12.2. Trends in AIDS incidence rates, selected EU member states, 2000-10 Italy

Latvia

Portugal

EU21

New cases per 100 000 population 12

0 2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Source: ECDC and WHO Regional Office for Europe (2011).

1 2 http://dx.doi.org/10.1787/888932703525

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

1.13. CANCER INCIDENCE

In 2008, an estimated 2.4 million new cases of cancer (excluding non-melanoma skin cancers) were diagnosed in EU member states (Ferlay et al., 2010), and of these 55% occurred among males and 45% among females. The most commonly diagnosed cancers were prostate, colorectal, breast and lung cancer. The risk of getting cancer before the age of 75 years was 26.5%, or around one in four. However, because the population of Europe is ageing, the rate of new cases of cancer is also expected to increase (EC, 2008b). Large regional inequalities exist in cancer incidence across European countries. In 2008, the incidence rate for all cancers combined was highest in Northern and Western Europe – Belgium, Denmark, France, Iceland, Ireland and Norway – at over 290 per 100 000 population, but was lower in some Mediterranean countries such as Cyprus, Greece, Malta and Turkey, at less than 220. Rates in Italy were above the EU average of 255 new cases per 100 000 population. Rates in central European countries varied, being highest in the Czech Republic and Hungary (around 290), similar to the EU average in Slovenia and the Slovak Republic (260), and below average in Bulgaria, Poland and Romania and other countries. Cancer incidence rates are higher for men in all EU member states (Figure 1.13.1). Here too there is great variation between countries; in Spain and Turkey, male incidence rates are 60% higher than female rates, whereas in Cyprus, Denmark and the United Kingdom they are less than 10% higher. In 2008, the average all cancer incidence rate among EU member states was 296 per 100 000 males and 227 per 100 000 females. In 2008, lung cancer was one of the most common cancers in Europe, being responsible for around 12% of all new cancer diagnoses, 16% for males and 7% for females. Ten of the 15 countries with male rates higher than the EU average were located in central Europe (Figure 1.13.2). Rates in Hungary, Poland, Slovenia were higher than 60 per 100 000 population. Male lung cancer incidence rates in Northern Europe (Finland, Iceland, Norway and Sweden) and some southern European countries (Cyprus, Malta and Portugal) were less than 40 per 100 000 population. Among females, lung cancer incidence was high in Denmark, but also Hungary, Iceland and the Netherlands, at over 25. Thirty per cent of all new cancer cases among women diagnosed in 2008 were cancers of the breast – the most common form of cancer among women. Incidence rates were high in Denmark and western European countries such as Belgium, France, Ireland and the Netherlands, at over 90 cases per 100 000 population (Figure 1.13.3). Rates in Central and Southern Europe were lower, with Greece, Latvia, Lithuania, Poland, Romania and Turkey all reporting less than 50 new cases per 100 000 population. There has been an increase in measured incidence rates of breast

cancer over the past decade, although death rates have declined or remained stable. Survival rates have also increased, due to earlier diagnosis and/or better treatment (see Indicator 4.8 “Screening, survival and mortality for breast cancer”). Prostate cancer has become the most commonly diagnosed cancer among males in most OECD countries, particularly among men over 65 years of age. Prostate cancer comprised one quarter (25%) of all new diagnoses in 2008. Rates were highest in Belgium, France and Ireland and northern European countries (Finland, Iceland, Norway and Sweden) (Figure 1.13.4). Rates were lower in a range of central and southern European countries, including Bulgaria, Greece, Romania and Turkey. At least part of the five-fold difference between countries with the highest and lowest incidence rates is due to under-registration of prostate cancer in some countries, as well as the use of sensitive diagnostic tests for early detection in others (Ferlay et al., 2007). The rise in the reported incidence of prostate cancer in many countries since the 1990s is due largely to the greater use of prostate specific antigen (PSA) tests, although the use of these has also fluctuated because of their cost and uncertainty about the long-term benefit to patients.

Definition and comparability Cancer incidence rates are based on numbers of new cases of cancer registered in a country in a year divided by the size of the corresponding population. The rates have been directly age-standardised to Segi’s world population to remove variations arising from differences in age structures across countries and over time. The source is GLOBOCAN 2008, at http://globocan.iarc.fr/. GLOBOCAN estimates for 2008 may differ to actual incidence for some countries, due to the projection methods used. Cancer registration is well established in a majority of EU member states, although the quality and completeness of cancer registry data may vary. In some countries, cancer registries only cover subnational areas. The international comparability of cancer incidence data can also be affected by differences in medical training and practice. The incidence of all cancers is classified to ICD-10 Codes C00-C97 (excluding non-melanoma skin cancer C44), lung cancer to C33-C34, breast cancer to C50 and prostate cancer to C61.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.13. CANCER INCIDENCE

1.13.1. All cancers incidence rates, males and females, 2008 Males Cyprus Greece Malta Romania Bulgaria Portugal Sweden Finland Austria United Kingdom Poland Estonia EU27 Latvia Netherlands Spain Italy Lithuania Slovenia Slovak Republic Luxembourg Germany Denmark Czech Republic Belgium Hungary Ireland France Turkey Montenegro Serbia FYR of Macedonia Iceland Switzerland Croatia Norway

1.13.2. Lung cancer incidence rates, males and females, 2008

Females

Males

187 190

175 136

233 241 253

200 180 207

267 270 271 275 280 281 286 296 304 306 310 310 317 320 320 324 331 335 325

191 241 240 201 261 186 204 227 193 277 187 252 208 233 223 254 246

349 351 352 356 361

259 276 236 285 255 182

113

231 239

185 205 197

262 306 313 315

266 236 229

338

270

100

Sweden Cyprus Portugal Finland Malta Austria Ireland United Kingdom Germany Denmark Italy Luxembourg EU27 Netherlands France Slovak Republic Greece Spain Bulgaria Romania Slovenia Latvia Czech Republic Lithuania Belgium Estonia Poland Hungary

Source: Ferlay et al. (2010).

29 31 33

6 12 6

37 38 38

17 24 26

42 43 45 46 47 47 48 49

16 35 11 18 15 27 15 11 10 8 9 10 16 7 17 7 18 9 19

52 53 54 55 55 55 56 56 57 64 71 81

Iceland Turkey Norway Switzerland Montenegro FYR of Macedonia Croatia Serbia

200 300 400 Age-standardised rates per 100 000 population

Females

5 35

17 17

57 58 60

8 14

40 60 80 100 Age-standardised rates per 100 000 population

Source: Ferlay et al. (2010).

1 2 http://dx.doi.org/10.1787/888932703544

1 2 http://dx.doi.org/10.1787/888932703563

1.13.3. Breast cancer incidence rates, females, 2008

1.13.4. Prostate cancer incidence rates, males, 2008

Greece Romania Lithuania Latvia Poland Estonia Slovak Republic Bulgaria Hungary Portugal Spain Austria Slovenia Cyprus EU27 Czech Republic Malta Sweden Germany Luxembourg Finland Italy United Kingdom Ireland Netherlands France Denmark Belgium

Greece Romania Bulgaria Hungary Slovak Republic Estonia Poland Cyprus Portugal Malta Spain Italy Slovenia EU27 United Kingdom Latvia Czech Republic Lithuania Netherlands Austria Denmark Luxembourg Germany Finland Sweden Belgium France Ireland

41 45 46 48 49 50 53 56 57 60 61 62 65 68 71 71 72 79 82 82 86 86 89 94 99 100 101 109

Turkey Montenegro FYR of Macedonia Serbia Croatia Norway Switzerland Iceland

28 50 54 57 64 74 89 96

50 75 100 125 150 Age-standardised rates per 100 000 females

Source: Ferlay et al. (2010).

1 2 http://dx.doi.org/10.1787/888932703582

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

16 20 22 32 40 43 44 47 50 51 57 58 63 63 64 66 67 67 68 71 73 75 83 83 96 101 118 126

Turkey Serbia Montenegro FYR of Macedonia Croatia Switzerland Norway Iceland

15 19 20 21 44 91 104 112

75 100 125 150 Age-standardised rates per 100 000 males

Source: Ferlay et al. (2010).

1 2 http://dx.doi.org/10.1787/888932703601

1.14. DIABETES PREVALENCE AND INCIDENCE

Diabetes is a chronic metabolic disease, characterised by high levels of glucose in the blood. It occurs either because the pancreas stops producing the hormone insulin (Type 1 diabetes), or through a combination of the pancreas having reduced ability to produce insulin alongside the body being resistant to its action (Type 2 diabetes). People with diabetes are at a greater risk of developing cardiovascular diseases such as heart attack and stroke if the disease is left undiagnosed or poorly controlled. They also have elevated risks for sight loss, foot and leg amputation due to damage to the nerves and blood vessels, and renal failure requiring dialysis or transplantation. Diabetes was the principal cause of death of more than 100 000 persons in EU member states in 2011, and is a leading cause of death in most developed countries. However, only a minority of persons with diabetes die from diseases uniquely related to the condition – in addition, about 50% of persons with diabetes die of cardiovascular disease, and 10-20% of renal failure (IDF, 2011). Diabetes is increasing rapidly in every part of the world, to the extent that it has now assumed epidemic proportions. Estimates suggest that more than 6% of the population aged 20-79 years in EU member states, or 30 million people, had diabetes in 2011, with 42% of diabetic adults aged less than 60 years (IDF, 2011; Whiting et al., 2011). If left unchecked, the number of people with diabetes in EU member states will reach more than 35 million in less than 20 years. Less than 5% of adults aged 20-79 years in Belgium, Iceland, Luxembourg, Norway and Sweden have diabetes, according to the International Diabetes Federation. This contrasts with Portugal, Cyprus and Poland, where 9% or more of the population of the same age have the disease (Figure 1.14.1). In Europe, abnormal glucose tolerance shows little association with affluence, except in a few countries. Type 1 diabetes accounts for only 10-15% of all diabetes cases. It is the predominant form of the disease in younger age groups in most developed countries. Based on disease registers and recent studies, the annual number of new cases of Type 1 diabetes in children aged under 15 years is high at 25 or more per 100 000 population in Nordic countries (Finland, Norway and Sweden) (Figure 1.14.2). Bulgaria, Croatia and Switzerland have less than ten new cases per 100 000 population. Alarmingly, there is evidence that Type 1 diabetes is developing at an earlier age among children.

The economic impact of diabetes is substantial. Health expenditure in EU member states in 2011 to treat and prevent diabetes and its complications was estimated at USD 110 billion (IDF, 2011). Around one-quarter of medical expenditure is spent on controlling elevated blood glucose, another quarter on treating long-term complication of diabetes, and the remainder on additional general medical care. Increasing costs reinforce the need to provide quality care for the management of diabetes and its complications. In April 2012, the European Diabetes Leadership Forum brought together a wide range of stakeholders to produce the Copenhagen Roadmap, outlining initiatives to improve diabetes prevention, early detection and intervention as well as management and control (European Diabetes Leadership Forum, 2012). Type 2 diabetes is largely preventable. A number of risk factors, such as overweight and obesity and physical inactivity are modifiable, and can also help reduce the complications that are associated with diabetes. But in most countries, the prevalence of overweight and obesity also continues to increase (see Indicator 2.7 “Overweight and obesity among adults”).

Definition and comparability The sources and methods used by the International Diabetes Federation for publishing national prevalence estimates of diabetes are outlined in their Diabetes Atlas, 5th edition (IDF, 2011; Guariguata et al., 2011). Country-level data were derived from studies published up to April 2011, and were only included if they met several criteria for reliability. Countries without national data sources are excluded. Studies from several European countries only provided self-reported data on diabetes. Studies only reporting known diabetes were adjusted to account for undiagnosed diabetes, based on sources with available data. Prevalence rates were adjusted to the World Standard Population to facilitate cross-national comparisons.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.14. DIABETES PREVALENCE AND INCIDENCE

1.14.1. Prevalence estimates of diabetes, adults aged 20-79 years, 2011 % 10

9.5

9.2

9.8 8.1

7.8

6.0 5.3

4.9

4.7

4.4

6.0

5.9

5.7

5.6

5.5

5.4

5.3

6.9

6.8

6.5

6.4

6.2

7.2

4.8

3.3

Tu r

tia

oa Cr

it z

l ga

us pr

r tu

a ov

ria

y ng

nl Fi

i te

an rm

It a

ur bo

m xe

Note: The data are age-standardised to the World Standard Population. Source: IDF (2011).

1 2 http://dx.doi.org/10.1787/888932703620

1.14.2. Incidence estimates of Type 1 diabetes, children aged 0-14 years, 2011 Cases per 100 000 population 60

57.6

50 43.1

27.9 24.5 22.2

11.1

10.4

9.4

11.3

12.2

12.1

13.0

18.0

17.3

17.1

15.6

15.5

15.4

14.9

13.6

13.3

13.2

18.6

18.2

14.7 9.2

9.1

d an

nd la

it z

tia oa Cr

m do

ed Sw

i te

s nd la

er th Ne

22 EU

nd la

a ni

ta al

to Es

g M

m iu

pr Cy

ic bl pu

ria

ga r tu

an Fr

ly It a

ia en

ce ee

Source: IDF (2011).

1 2 http://dx.doi.org/10.1787/888932703639

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

1.15. DEMENTIA PREVALENCE

Dementia describes a variety of brain disorders which progressively lead to brain damage, and cause a gradual deterioration of the individual’s functional capacity and social relations. It is one of the most important causes of disability among the elderly, placing a large burden not only on sufferers, but also on carers. Alzheimer’s disease is the most common form of dementia, representing about 60% to 80% of cases. Successive strokes that lead to multi-infarct dementia are another common cause. Currently, there is no treatment that can halt dementia, but pharmaceutical drugs and other interventions can help treat symptoms. In 2009, there were an estimated 6.8 million people aged 60 years and over suffering from dementia in EU member states, accounting for around 6% of the population in that age group, according to estimates by Wimo et al. (2010) (Figure 1.15.1). France, Italy, Spain, Sweden and Switzerland had the highest prevalence, with 6.3% to 6.6% of the population aged 60 years or older. This contrasts with less than 5% in Bulgaria, the Czech and Slovak Republics, Malta and Romania, as well as the Former Yugoslav Republic of Macedonia, Montenegro and Turkey. Clinical symptoms of dementia usually begin after the age of 60, and the prevalence increases markedly with age (Figure 1.15.2). The disease affects more women than men. In Europe, 14% of men and 16% of women aged 80-84 years were estimated as having dementia in 2009, compared to less than 4% among those under 75 years of age (Alzheimer Europe, 2009). For the very elderly aged 90 years and over, the figures rise to 31% of men and 47% of women. Earlyonset dementia among people aged younger than 65 years is rare; they comprise less than 2% of the total number of people with dementia. People with Alzheimer’s disease and other dementias are high users of long-term care services. Wimo and colleagues (2010) used cost-of-illness studies from different countries to estimate the direct costs of dementia, including only the resources used to care for people with dementia. In 2009, the direct costs of dementia were estimated at 0.5% of GDP on average among EU member states.

As the number of older persons suffering from dementia is already large, and is expected to grow in the future, dementia has become a health policy priority in many countries. National policies typically involve measures to improve early diagnosis, promote quality of care for people with dementia, and support informal caregivers (Wortmann, 2009; Juva, 2009; Ersek et al., 2009; Kenigsberg, 2009). In January 2011, the European Parliament adopted a resolution calling for dementia to be made an EU health priority and urging member states to develop dedicated national plans and strategies (only a small number of countries including France and the United Kingdom, along with Norway, currently have national strategies in place). These strategies should address the social and health consequences, as well as services and support for sufferers and their families. A Joint Action between European member states aims to improve knowledge on dementia and its consequences and to promote the exchange of information to preserve health, quality of life, autonomy and dignity of people living with dementia and their carers (ALCOVE, 2012).

Definition and comparability Dementia prevalence rates are based on estimates of the total number of persons aged 60 years and over living with dementia divided by the size of the corresponding population. Estimates by Wimo et al. (2010) are based on previous national epidemiological studies and meta-analyses. Given the divergence in scale and accuracy of the sources used across countries, the estimates should be used with caution.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.15. DEMENTIA PREVALENCE

1.15.1. Prevalence of dementia, population aged 60 years and over, 2009 % 7

6.6

6.5

6.3

6.2

6.4 6.1

6.0

5.9

5.7

5.6

5.5

5.4

6.4 5.6

5.3

5.2

5.0

5.5 5.1

4.9

4.8

4.7 4.4

4.4

4.2

4 3.2

3 2 1

ce It a l Sp y Un ai S i te w n d ed K i en ng d B e om lg iu Au m st Ge r ia rm a C y ny pr Po us rt De uga L u nm l xe a m rk bo u Fi rg nl an Ne E d th U2 er 7 la n Ir e d s la Sl nd ov en Es ia to n Po i a Li lan th d ua ni La a Hu t v i a ng Sl ov G ar y ak re Re e c e pu C z B blic e c ul g h Re ar i a pu Ro b l i c m an ia M al ta Sw it z er la No nd rw a Se y rb Ic i a el an d F Y M Cr o R on t a t i of en a M eg ac ro ed on Tu ia rk ey

Source: Wimo et al. (2010).

1 2 http://dx.doi.org/10.1787/888932703658

1.15.2. Age- and sex-specific prevalence of dementia in EU member states, 2009 Male

Female

Prevalence (%) 60

0 60-64

65-69

70-74

75-79

80-84

85-89

90-94

95 and over Age group

Source: Alzheimer Europe (2009).

1 2 http://dx.doi.org/10.1787/888932703677

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

1.16. ASTHMA AND COPD PREVALENCE

Asthma is a disease of the bronchial tubes characterised by “wheezing” during breathing, shortness of breath or coughing. Asthma is the single most common chronic disease among children, and also affects many adults. It is a significant public health problem and a high-burden disease for which prevention is partly possible and treatment can be effective. Its causes are not well understood, but effective medicines are available to help in maintaining quality of life and avoiding disability and death (The Union/ ISAAC, 2011). Chronic obstructive pulmonary disease (COPD) – the term now used to describe chronic bronchitis and emphysema – is another high-burden disease causing disability and impairing quality of life, as well as generating high costs. COPD is characterised by difficult breathing that is not fully reversible and usually progressive. Patients are often smokers or ex-smokers, and their symptoms rarely develop before age 40. COPD is among the leading causes of chronic morbidity and mortality in the EU. Approximately 200 000 to 300 000 people die each year in Europe because of COPD, and among respiratory diseases, it is the leading cause of lost work days (European Lung Foundation, 2012). COPD is preventable and treatable. Proper management of both asthma and COPD in primary care settings can reduce exacerbation and costly hospitalisation (see Indicator 4.1 “Avoidable admissions: Respiratory diseases”). In response to a health survey question asking whether adults aged 15 years and over had asthma during the last 12 months, prevalence ranged from 1.6% in Romania, to 7.0% in France (Figure 1.16.1). Rates also exceeded 5% in Germany, Hungary and Malta, and were less than 3% in Bulgaria, Estonia, Latvia, Romania and the Slovak Republic. Among 17 EU member states the average prevalence rate was 3.8%. Asthma was more commonly reported by females (4.3% vs. 3.3% for males). Slovenia is an exception, with a slightly higher male prevalence. The largest female-male disparity was in Turkey (5% vs. 2.5%), whereas no disparity existed in Cyprus (both 3.9%). The reported prevalence of COPD among adults aged 15 years and over ranged from 1.2% in Malta, to 4.7% in Hungary, and 6.2% in Turkey (Figure 1.16.2). Among 16 EU member states, average prevalence was 3.1%, with slightly higher prevalence among females (3.5% vs. 2.9%). In Cyprus, France, Romania and Spain, however, prevalence was higher among males. The prevalence of COPD also increases with age. Persons with low levels of education are more than twice as likely to report COPD than those with high levels

(Figure 1.16.3). Large disparities in COPD rates between persons with higher and lower levels of education are evident in Belgium, Romania, Spain and Estonia. Persons from low socio-economic groups also report higher rates of smoking, which is the major risk factor for COPD. The lower reported asthma and COPD prevalence among new EU member states in all likelihood reflects underdiagnosis and undertreatment, although rates in these countries have increased sharply in recent years, possibly reflecting greater awareness of this condition along with changes in diagnostic practice (Braman, 2006; The Union/ISAAC, 2011). A number of EU actions reflect an increased focus on asthma and COPD. These include the Council Conclusions on prevention, early diagnosis and treatment of chronic respiratory diseases in children (12/2011), and the Commission Reflection Paper on Chronic Diseases (03/2012). Both aim to identify issues, gaps and suggestions for action to improve current policies and activities on chronic diseases such as asthma and COPD.

Definition and comparability Estimates of the prevalence of asthma and chronic obstructive pulmonary disease (COPD) are derived from European Health Interview Survey questions, conducted in many EU member states between 2006 and 2010. Typically, respondents were asked: “Do you have or have you ever had any of the following diseases or conditions? 1) Asthma (allergic asthma included) (yes/no). 2) Chronic bronchitis, chronic obstructive pulmonary disease, emphysema (yes/no). If yes: Was this disease/condition diagnosed by a medical doctor? (yes/no). Have you had this disease/ condition in the past 12 months? (yes/no).” The same survey also asked for information on age, sex and educational level. Data rely on self-report, and are subject to errors in recall. Data are not age-standardised, with aggregate country estimates representing crude rates among respondents aged 15 years and over. The data, therefore, exclude the prevalence of childhood asthma (age 0-14 years).

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

1.16. ASTHMA AND COPD PREVALENCE

1.16.1. Self-reported asthma, 2008 (or nearest year) France

1.16.2. Self-reported COPD, 2008 (or nearest year) Hungary

7.0

Germany

5.3

France

Hungary

5.3

Belgium

Malta

5.2

Austria

4.3

Spain

4.3

Belgium

4.3 4.0

Austria

3.7

Spain

3.5

Bulgaria

3.3

Latvia

3.3

Slovak Republic

3.3

4.2

Czech Republic

4.7

4.0

Cyprus

3.9

EU17

3.8

Greece

3.6

Poland

3.6

Slovenia

3.1

EU16

3.1

Poland

3.0

Greece

Slovenia

2.9

3.5

Slovak Republic

Czech Republic

2.7

Estonia

2.3

Latvia

2.3

Bulgaria

Cyprus

2.1

Romania

1.7

Malta

1.6

Turkey 2

1.2

Turkey

3.8

2.4

Estonia

2.0

Romania

2.7

6.2

6 8 10 % of population aged 15 and over

Source: Eurostat Statistics Database.

6 8 10 % of population aged 15 and over

Source: Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932703696

1 2 http://dx.doi.org/10.1787/888932703715

1.16.3. Self-reported COPD by highest attained level of education, 2008 (or nearest year) Low

Medium

High

% of population aged 15 and over 10

4.4

4.3

1.8 1.0 0.6

0.7

0.8

1.5

2.0

2.1

2.4

2.6

2.8 2.8

2.9

3.9 1.5 1.4

1.5 1.6

1.9

1.8 1.9

2.5

2.9 2.7

4.3

4.5

4.5 2.1

2.6

3.2 2.8

4.7

4.8 1.9

1.8 1.5

1.4

2.9

3.1 2.7

2.3

3.2

3.3

3.5

3.8

5.0

4.7

5.7

6.3

6.6

7.0

7.4

y ke

ta al M

Tu r

a ni to

ic bl

us pr

ia Sl

tv La

pu Re ak

ov Sl

ic bl

nd la Po

ce ee

ar lg Bu

n ai Sp

ria st Au

ce Fr

m iu lg Be

Source: Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932703734

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

Health at a Glance: Europe 2012 ÂŠ OECD 2012

Chapter 2

Determinants of health

2.1. Smoking and alcohol consumption among children . . . . . . . . . . . . . . .

2.2. Overweight and obesity among children . . . . . . . . . . . . . . . . . . . . . . . . .

2.3. Fruit and vegetable consumption among children. . . . . . . . . . . . . . . . .

2.4. Physical activity among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.5. Smoking among adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.6. Alcohol consumption among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.7. Overweight and obesity among adults. . . . . . . . . . . . . . . . . . . . . . . . . . .

2.8. Fruit and vegetable consumption among adults . . . . . . . . . . . . . . . . . .

2.1. SMOKING AND ALCOHOL CONSUMPTION AMONG CHILDREN

Regular smoking or excessive drinking in adolescence has both immediate and long-term health consequences. Children who establish smoking habits in early adolescence increase their risk of cardiovascular diseases, respiratory illnesses and cancer. They are also more likely to experiment with alcohol and other drugs. Alcohol misuse is itself associated with a range of social, physical and mental health problems, including depressive and anxiety disorders, obesity and accidental injury (Currie et al., 2012). Results from the Health Behaviour in School-aged Children (HBSC) surveys, a series of collaborative crossnational studies conducted in most EU member states, allow for monitoring of smoking and drinking behaviours among adolescents. Across all EU member states who responded to the survey, the proportions of 15-year-old boys and girls who smoke are similar, but more boys get drunk. Boys and girls in Austria, Croatia, the Czech Republic, Hungary, Latvia and Lithuania smoke most, with more than 25% reporting that they smoke at least once a week (Figure 2.1.1). In contrast, less than 15% of 15-year-olds in Nordic countries (Denmark, Iceland, Norway and Sweden), Ireland, Poland, Portugal and the United Kingdom smoke weekly. A number of countries report higher rates of smoking for girls, although only in the Czech Republic and Spain is the difference in excess of 5%. Smoking is more prevalent among boys in Latvia, Lithuania and Romania, where the difference is 10% or greater. Drunkenness at least twice in their lifetime is reported by more than 40% of 15-year-olds in the Czech Republic, Denmark, Estonia, Finland, Hungary, Latvia, Lithuania, Slovenia and the United Kingdom (Figure 2.1.2). Much lower rates (less than 20%) are reported in Italy, Luxembourg and the Netherlands, as well as Iceland and the Former Yugoslav Republic of Macedonia. Across all surveyed EU member states, boys are more likely than girls to report repeated drunkenness (36% vs. 31%). Croatia, Hungary, Lithuania and Romania have the biggest differences, with rates of alcohol abuse among boys at least 10% higher than those of girls. In four countries, Finland, Spain, Sweden and the United Kingdom, around 5% more girls than boys report repeated drunkenness. Recent smoking and drinking rates for 15-year-old boys and girls are compared in Figure 2.1.3. Countries

above the 45 degree line have higher rates for boys, and countries below the line higher rates for girls. Countries with higher rates of smoking among boys also tend to report higher rates for girls, with the same finding for drinking rates. Rates of smoking and drunkenness are also available for 13-year-olds (Currie et al., 2012). At this age, around 5% of children surveyed across the entire European Union smoke weekly, and in the Czech Republic, Estonia, Latvia, Romania and the Slovak Republic, the figure is higher at 8% or more. Over one in ten children in a range of countries including Croatia, the Czech Republic, Greece, Italy, Romania, the Slovak Republic and the United Kingdom have experienced drunkenness at least twice. In Croatia, the Czech Republic, Greece, Italy and Romania, high rates of repeated drunkenness at 13 are seen for boys. Risk-taking behaviours among adolescents are falling, with regular smoking for both boys and girls and drunkenness rates for boys showing some decline from the levels of the late 1990s (Figure 2.1.4). Levels of smoking for both sexes are at their lowest for a decade with, on average, fewer than one in five children of either sex smoking regularly. However, increasing rates of smoking and drunkenness among adolescents in Estonia, Hungary, Latvia, Lithuania and Poland are cause for concern.

Definition and comparability Estimates for smoking refer to the proportion of 15-year-old children who self-report smoking at least once a week. Estimates for drunkenness record the proportions of 15-year-old children saying they have been drunk twice or more in their lives. Data for 24 European Union member states and five other countries are from the Health Behaviour in School-aged Children (HBSC) surveys undertaken between 1993-94 and 2009-10. Data are drawn from school-based samples of 1 500 in each age group (11-, 13- and 15-year-olds) in most countries. Turkey was included in the 2009-10 HBSC survey, but children were not questioned on drinking and smoking.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

2.1. SMOKING AND ALCOHOL CONSUMPTION AMONG CHILDREN

2.1.1. Smoking among 15-year-olds, 2009-10

2.1.2. Drunkenness among 15-year-olds, 2009-10

Smoking at least once a week

Drunk at least twice in life

Boys Austria Czech Republic Hungary Italy Spain Latvia Lithuania France Finland Luxembourg Slovenia EU24 Belgium Netherlands Slovak Republic Estonia Germany Romania Sweden United Kingdom Ireland Denmark Greece Poland Portugal

Boys

Girls 29

25 22 23 22 23

28 26 26

21 20 20 19 20 19

Denmark Lithuania Finland United Kingdom Estonia Latvia Czech Republic Slovenia Spain Hungary Austria Slovak Republic EU24 Ireland Germany Poland Sweden Belgium Greece Portugal Romania France Luxembourg Netherlands Italy

19 20 18 19 17 16 17 15 17

15 15 15

10 12

14 13

12 10

11 25

Croatia Switzerland FYR of Macedonia Norway Iceland

15 9 8 7

9 9

Source: Currie et al. (2012).

2.1.3. Risk behaviours of 15-year-olds by sex, 2009-10 Regular cigarette smoking

28 30 27 27 21 23 19 18

47 39

31 31

51 46

39 36

35 35

27 29 26

18 17

47 26

20 17 19 14

19 28 26 26 20

16 18 8

80 %

1 2 http://dx.doi.org/10.1787/888932703772

2.1.4. Trends in repeated drunkenness and regular smoking among 15-year-olds, 14 EU countries Boys

40 DNK

ROU

HUN HRV

DEU POL IRL

40 36

32 27

EST CZE

GBR FIN

1993-94

1997-98

LVA SVK GRC BEL EST FRA NOR LUX ROU CHE PRT AUT NLD HUN LUX CHE CZE MKD ITA ITA FRA SWE GRC FIN,SVN ISL BEL DNK POL ESP MKD NLD IRL SWE DEU ISL PRT GBR NOR

SVK AUT

HRV LTU

SVN

LVA

LTU

Girls

Repeated drunkenness

Boys aged 15 (%)

42 42

Source: Currie et al. (2012).

1 2 http://dx.doi.org/10.1787/888932703753

40 %

56 55

Norway Croatia Switzerland Iceland FYR of Macedonia

Girls

ESP

2001-02

2005-06

2009-10

2005-06

2009-10

Regular smoking

50 40 30

20 19

5 5

55 65 Girls aged 15 (%)

Source: Currie et al. (2012).

1 2 http://dx.doi.org/10.1787/888932703791

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

1993-94

1997-98

2001-02

Source: Currie et al. (2000); Currie et al. (2004); Currie et al. (2008); Currie et al. (2012); WHO (1996). 1 2 http://dx.doi.org/10.1787/888932703810

2.2. OVERWEIGHT AND OBESITY AMONG CHILDREN

Children who are overweight or obese are at greater risk of poor health in adolescence and also in adulthood. Among young people, orthopaedic problems and psychosocial problems such as low self-image, depression and impaired quality of life can result from overweight. Excess weight problems in childhood are associated with an increased risk of being an obese adult, at which point cardiovascular disease, diabetes, certain forms of cancer, osteoarthritis, a reduced quality of life and premature death become health concerns (Sassi, 2010; Currie et al., 2012). Evidence suggests that even if excess childhood weight is lost, adults who were obese children retain an increased risk of cardiovascular problems. And although dieting can combat obesity, children who diet are at a greater risk of putting on weight following periods of dieting. Eating disorders, symptoms of stress and postponed physical development can also be products of dieting (WHO Europe, 2009). Among 15-year-olds in EU member states, boys tend to report excess weight more often than girls; one-in-six boys and one-in-ten girls reported being overweight or obese in 2009-10 (Figure 2.2.1). More than 15% of adolescents in southern European countries (Greece, Italy, Portugal and Spain), as well as in Croatia, Iceland, Luxembourg and Slovenia report being overweight or obese. Fewer than 10% of children in Latvia and Lithuania, as well as in Denmark, France and the Netherlands report overweight or obesity. Boys’ and girls’ perceptions of having weight problems often differ from their reported weight. Among 15-year-olds, 40% of girls and 22% of boys across EU member states thought they were too fat. Further, there is also no clear association between weight problems and weight reduction behaviours, with 22% of girls and 9% of boys reporting that they engage in weight-reduction behaviour; twice the rate of girls who report being overweight or obese, but only half that of boys. Young people who report being overweight are more likely to miss eating breakfast, are less physically active, and spend more time watching television (Currie et al., 2012). Reported rates of excess weight have increased slightly over the past decade in most EU member states (Figure 2.2.2). Average reported rates of overweight and

ob esity acro ss the EU increased b etwe en 20 01-02 and 2009-10 from 11% to 13% of 15-year-olds. The largest increases during the eight year period were found in the Czech Republic, Estonia, Poland, Romania and Slovenia, all greater than 5%. Only Denmark and the United Kingdom report any significant reductions in the proportion of overweight or obese at age 15 between 2001-02 and 2009-10, although non-response rates to questions about selfreported height and weight require cautious interpretation. Childhood is an important period for forming healthy behaviours, and the increased focus on obesity at both national and international levels has stimulated the implementation of many community-based initiatives in European countries in recent years. Studies show that locally focused interventions, targeting children to 12 years of age can be effective in changing behaviours. Schools provide an opportunity to ensure that children understand the importance of good nutrition and physical activity, and can benefit from both. Teachers and health professionals are often involved as providers of health and nutrition activities, and the most frequent community-based initiatives target professional training, the social or physical environment and actions for parents (Bemelmans et al., 2011).

Definition and comparability Estimates of overweight and obesity are based on body mass index (BMI) calculations using child selfreported height and weight. Overweight and obese children are those whose BMI is above a set of ageand sex-specific cut-off points (Cole et al., 2000). Self-reported height and weight is subject to underreporting, missing data and error, and requires cautious interpretation. Data for 24 EU member states and six other countries are from the Health Behaviour in School-aged Children (HBSC) surveys undertaken between 2001-02 and 2009-10. Data are drawn from school-based samples of 1 500 in each age group (11-, 13- and 15-year-olds) in most countries.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

2.2. OVERWEIGHT AND OBESITY AMONG CHILDREN

2.2.1. Reported overweight (including obesity) among 15-year-olds, 2009-10 Girls

Boys Portugal Greece Slovenia Ireland Luxembourg Spain United Kingdom Austria Finland Hungary Italy Czech Republic Germany Poland EU24 Estonia Belgium Denmark Romania France Latvia Slovak Republic Sweden Lithuania Netherlands

15 13 13 12 12 12 11 11 11 11 11 10 10 10 10 9 9 8 8 7 7 7 7 5 5

11 10 7 6 6

28 23 16 22 19 12 19 17 19 22 19 18 17 17 16 15 10 20 13 13 15 17 13 11

Iceland Norway Croatia Switzerland FYR of Macedonia Turkey

30 % of 15-year-olds

20 17 23 14 21 17

30 % of 15-year-olds

Source: Currie et al. (2012), based on HBSC survey.

1 2 http://dx.doi.org/10.1787/888932703829

2.2.2. Change in reported overweight among 15-year-olds, 2001-02, 2005-06 and 2009-10 2001-02

2005-06

2009-10

% of 15-year-olds 25

13 14

17 17

12 12

12 10

11 11 10

9 6

18 16

18 17

15 13

12 11

17 17

15 16 15 16

14 14

12 13

12 12

11 12

11 11 12 12

11 11

12 11

14 13

it z

er la nd T ur of ke M y ac ed on i No a rw ay Cr oa tia Ic el an d

ce ee

l Sl

r tu

It a

m xe Lu

n ai Sp

y ng

ria st

ia an

Ir e

y an

d an

nd la

24 EU

ni to

do ng

i te

ic Be Un

a ni

er th Ne

Source: Currie et al. (2004); Currie et al. (2008); Currie et al. (2012), based on HBSC surveys.

1 2 http://dx.doi.org/10.1787/888932703848

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

2.3. FRUIT AND VEGETABLE CONSUMPTION AMONG CHILDREN

Nutrition is important for childrenâ&#x20AC;&#x2122;s development and long-term health. Eating fruit during adolescence, for example, in place of high-fat, sugar and salt products, can protect against health problems such as obesity, diabetes, and heart problems. Moreover, eating fruit and vegetables when young can be habit forming, promoting healthy eating behaviours for later life. A number of factors influence the amount of fruit consumed by adolescents, including family income, the cost of alternatives, preparation time, whether parents eat fruit, and the availability of fresh fruit which can be linked to the country or local climate (Rasmussen et al., 2006). Fruit and vegetable consumption have a high priority as indicators of healthy eating in most European countries. In European countries in 2009-10, only around onethird of girls and one-quarter of boys aged 15 years ate at least one piece of fruit daily, according to the latest Health Behaviour in School-aged Children (HBSC) survey (Currie et al., 2012). Overall, boys in Denmark, Portugal and Italy, and girls in Denmark, Norway, the Former Yugoslav Republic of Macedonia and Switzerland had the highest rates of daily fruit consumption. Fruit consumption was relatively low in Estonia, Latvia, Lithuania and Poland, and in contrast to other Nordic countries, Finland and Sweden, with rates of around one-in-four among girls and one-in-five for boys (Figure 2.3.1). In all countries, girls were more likely to eat fruit daily. The gap between the fruit consumption of boys and girls is largest at age 15 for most countries, with the greatest disparities found in Denmark, Finland, Germany and Norway. Daily vegetable eating was also reported by around one-third of girls and quarter of boys on average across EU member states in 2009-10 (Figure 2.3.2). Girls in Belgium most commonly ate vegetables daily (60%), followed by Denmark, France and Switzerland (45-50%). Belgium also led the way for boys (46%), with close to 40% in France and Ireland. Eating vegetables daily was less common in Austria, Estonia and Spain, as well as in Croatia (girls), and Finland and Latvia (boys). Similar to fruit eating, in all countries a higher proportion of girls ate vegetables daily. The disparity was especially large in Finland, where 35% of girls, but only 14% of

boys reported eating vegetables each day. Denmark and Germany also had large differences, although rates were comparatively high for both boys and girls in Denmark. In most countries, it was more common for 15-year-olds to report eating fruit daily, rather than vegetables (Figure 2.3.3). However, in a number of western European countries, including Belgium, the Netherlands, Sweden, Ireland and France, daily vegetable eating was more common. Average reported rates of daily vegetable consumption a c ro s s E U m e m b e r s t a t e s s h owe d s o m e i n c re a s e between 2001-02 and 2009-10, for both girls and boys (Figure 2.3.3). Fruit consumption however was less clear, with a small increase among girls, while the rates for boys have remained largely unchanged. Effective and targeted strategies are required to ensure that children are eating enough fruit and vegetables to conform with recommended national dietary guidelines. A study of European school children found that they generally hold a positive attitude toward fruit intake, and report good availability of fruit at home, but lower availability at school and during leisure time. Increased accessibility to fruit and vegetables, combined with educational and motivational activities can help in increasing both fruit and vegetable consumption (Sandvik et al., 2005).

Definition and comparability Dietary habits are measured here in terms of the proportions of children who report eating fruit and vegetables at least every day or more than once a day. In addition to fruit and vegetables, healthy nutrition also involves other types of foods. Data for 24 EU member states and six other countries are from the Health Behaviour in School-aged Children (HBSC) surveys undertaken between 2001-02 and 2009-10. Data are drawn from school-based samples of 1 500 in each age group (11-, 13- and 15-year-olds) in most countries.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

2.3. FRUIT AND VEGETABLE CONSUMPTION AMONG CHILDREN

2.3.1. Daily fruit eating among 15-year-olds, 2009-10 Boys Denmark Belgium Czech Republic Germany Luxembourg Romania Italy Portugal United Kingdom France Slovenia Austria Ireland Spain EU24 Slovak Republic Netherlands Finland Lithuania Greece Estonia Hungary Latvia Sweden Poland

2.3.2. Daily vegetable eating among 15-year-olds, 2009-10

Girls

Boys 56

34 40

23 35

28 31

35 35

26 31

26 27

27 25 26

Norway FYR of Macedonia Switzerland Turkey Iceland Croatia

29 41

30 37

23 35

23 24

60 %

Source: Currie et al. (2012).

Girls 60

46 49

33 47

38 39

42 42

35 40

30 36

14 33

21 30

21 28

19 26

22 20 21

Switzerland FYR of Macedonia Norway Turkey Iceland Croatia

Belgium Denmark France Ireland Netherlands United Kingdom Sweden Czech Republic Finland EU24 Germany Greece Luxembourg Romania Poland Lithuania Portugal Italy Slovenia Latvia Slovak Republic Spain Austria Hungary Estonia

34 38

27 33

23 31

21 27

19 19

60 %

Source: Currie et al. (2012).

1 2 http://dx.doi.org/10.1787/888932703867

2.3.3. Daily fruit and vegetable eating among 15-year-olds, 2009-10

1 2 http://dx.doi.org/10.1787/888932703886

2.3.4. Trends in daily fruit and vegetable eating among 15-year-olds, 21 EU countries, 2001-02 to 2009-10 2001-02

% 40

Daily vegetable eating (%) 60

2005-06

2009-10

Fruits

BEL

Vegetables

50 35

34 34

FRA IRL 40 NLD

CHE

MKD LUX NOR

CZE POL ROU TUR FIN DEU PRT LTU SVN ITA HUN HRV LVA ESP EST AUT ISL, SVK

DNK

GBR

SWE GRC

25 24

24 24 23

10 10

50 60 Daily fruit eating (%)

Source: Currie et al. (2012).

1 2 http://dx.doi.org/10.1787/888932703905

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

Girls

Boys

Girls

Boys

Source: Currie et al. (2004); Currie et al. (2008); Currie et al. (2012). 1 2 http://dx.doi.org/10.1787/888932703924

2.4. PHYSICAL ACTIVITY AMONG CHILDREN

Undertaking physical activity in adolescence is beneficial for health, and can set standards for adult physical activity levels, thereby influencing health outcomes in later life. Research supports the role that physical activity has in child and adolescent development, learning and wellbeing, and in the prevention and treatment of a range of youth health issues including asthma, mental health, bone health and obesity. More direct links to adult health are found between physical activity in adolescence and its effect on overweight and obesity and related diseases, breast cancer rates and bone health in later life. The health effects of adolescent physical activity are sometimes dependent on the activity type, e.g. water physical activities in adolescence are effective in the treatment of asthma, and exercise is recommended in the treatment of cystic fibrosis (Hallal et al., 2006; Currie et al., 2012). One extensive study recommends that children participate in at least 60 minutes of moderate-to-vigorous physical activity daily, although evidence suggests that many children do not meet these guidelines (Strong et al., 2005; Borraccino et al., 2009; Hallal et al., 2012). Some of the factors influencing the levels of physical activity undertaken by adolescents include the availability of space and equipment, the childâ&#x20AC;&#x2122;s present health conditions, their school curricula and other competing pastimes. Only one-in-five children in EU member states report that they undertake moderate-to-vigorous exercise regularly, according to results from the 2009-10 HBSC survey (Figure 2.4.1). At age 11, Austria, Ireland and Spain stand out as strong performers with over 30% of children reporting exercising for at least 60 minutes per day over the past week. At age 15, children in Ireland maintain their place, along with the Czech and Slovak Republics, at 20%. Country rankings vary according to the childâ&#x20AC;&#x2122;s age. Children in Denmark, France and Italy were least likely to report exercising regularly. Italy appears at the lower end for both boys and girls, and at both ages. A higher proportion of boys consistently reported undertaking physical activity, whether moderate or vigorous, across all countries and all age groups (Figures 2.4.2 and 2.4.3). It is of concern that physical activity tends to fall between ages 11 to 15 for most European countries, with

boys in Italy the only exception, although they have the lowest rate of physical activity at age 15. In Austria, Finland, Norway and Spain, the rates of exercising among boys halve between ages 11 and 15. The rates of girls exercising to recommended levels also fall between the ages of 11 and 15 years. In many countries, rates for 15-year-old girls are less than half of those at age 11, and in Austria, Ireland, Romania and Spain, rates of physical activity among girls fall by over 60%. The change in activity levels between 11- and 15-year-olds may reflect a move to different types of activity, since free play is more common among younger children, and structured activities at school or in sports clubs among older groups. Boys tend to be more physically active than girls in all countries, also suggesting that the opportunities to undertake physical activity may be gender-biased (Currie et al., 2012). Daily moderate-to-vigorous physical activity for 2005-06 and 2009-10 averaged across 21 EU member states are shown in Figure 2.4.3. Reported levels fell slightly for both boys and girls, and in all age groups, except boys aged 15 years.

Definition and comparability Data for physical activity considers the regularity of moderate-to-vigorous physical activity as reported by 11-, 13- and 15-year-olds for the years 2005-06 and 2009-10. Moderate-to-vigorous physical activity refers to exercise undertaken for at least an hour each day which increases the heart rate, and leaves the child out of breath sometimes. Data for 24 EU member states and six other countries are from the Health Behaviour in School-aged Children (HBSC) surveys. Data are drawn from schoolbased samples of 1 500 in each age group in most countries.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

2.4. PHYSICAL ACTIVITY AMONG CHILDREN

2.4.1. Daily moderate-to-vigorous physical activity, 11- and 15-year-olds, 2009-10 Girls aged 11

Girls aged 15

Boys aged 11

Boys aged 15

Girls

Boys 12

26 10

25 14

22 12

20 10

20 12

19 13

19 18

13 11

12 8

19 9

20 28

43 41

25 38

17 28

27 25

24 28

19 24

24 23

18 19

16 19

14 21

18 14

16 21

14 10

FYR of Macedonia Croatia Turkey Iceland Norway Switzerland

50 %

Austria Ireland Spain Finland Czech Republic Poland Hungary Slovak Republic Germany Romania Slovenia United Kingdom EU24 Netherlands Latvia Luxembourg Lithuania Sweden Belgium Estonia Portugal Greece Denmark France Italy

22 27

18 25

12 20

50 %

Source: Currie et al. (2012).

1 2 http://dx.doi.org/10.1787/888932703943

2.4.2. Vigorous physical activity for two or more hours per week, 15-year-olds, 2009-10

2.4.3. Trends in daily moderate-to-vigorous physical activity, 21 EU countries, 2005-06 to 2009-10

Girls (%) 80

2005-06

% 40 DNK

2009-10

Girls

Boys

NOR 60

ROU

DEU LUX ISL FIN BEL CHE SWE GBR GRC EST LVA AUT IRL SVK FRA SVN ITA ESP HUN POL CZE PRT LTU MKD HRV

29 27 24

19 14

13 11 9

TUR

0 0

80 Boys (%)

Source: Currie et al. (2012).

1 2 http://dx.doi.org/10.1787/888932703962

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

Age 11

Age 13

Age 15

Age 11

Age 13

Age 15

Source: Currie et al. (2008); Currie et al. (2012). 1 2 http://dx.doi.org/10.1787/888932703981

2.5. SMOKING AMONG ADULTS

Tobacco is responsible for about one-in-ten adult deaths worldwide, equating to about 5 million deaths each year (WHO, 2012a). It is a major risk factor for at least two of the leading causes of premature mortality â&#x20AC;&#x201C; circulatory disease and cancer, increasing the risk of heart attack, stroke, lung cancer, cancers of the larynx and mouth, and pancreatic cancer. Smoking also causes peripheral vascular disease and hypertension. In addition, it is an important contributory factor for respiratory diseases such as chronic obstructive pulmonary disease (COPD), while smoking among pregnant women can lead to low birth weight and illnesses among infants. It remains the largest avoidable risk to health in European countries. The proportion of daily smokers among the adult population varies greatly across countries (Figure 2.5.1). Only seven of 27 EU member states had rates of less than 20% of the adult population smoking daily in 2010. Rates were lowest in Finland, Malta, Luxembourg, Portugal, Slovenia, the Slovak Republic and Sweden, as well as Iceland and Norway. Although large disparities remain, smoking rates across most EU member states have declined. On average, smoking rates have decreased by about 5 percentage points since 2000, with a higher decline among men than women. Large declines occurred in Denmark (31% to 20%), Latvia (42% to 28%), Luxembourg (26% to 18%), and the Netherlands (29% to 21%), as well as in Norway and Iceland. Greece maintained the highest level of smoking around 2010, along with Bulgaria and Ireland, with close to 30% or more of the adult population smoking daily. The Czech Republic is one of the few EU member states where smoking rates appear to be increasing. In the post-war period, most European countries tended to follow a general pattern marked by very high smoking rates among men (50% or more) through to the 1960s and 1970s, while the 1980s and the 1990s were characterised by a downturn in tobacco consumption. Much of this decline can be attributed to policies aimed at reducing tobacco consumption through public awareness campaigns, advertising bans and increased taxation, in response to rising rates of tobacco-related diseases (EC, 2012c). In addition to government policies, actions by anti-

smoking interest groups were very effective in reducing smoking rates by changing beliefs about the health effects of smoking. Smoking prevalence among men is higher in all EU member states except in Sweden (Figure 2.5.2). In other Nordic countries (Denmark, Iceland, Norway), as well as in the United Kingdom, male and female smoking rates are close to equal. In 2010, the gender gap in smoking rates was particularly large in Latvia and Lithuania, as well as in Cyprus, Bulgaria, Romania and Turkey. Female smoking rates continue to decline in most countries, and in several at a faster pace than male rates. However, female smoking rates have shown little or no decline since 2000 in three countries: the Czech Republic, France and Italy. Several studies provide strong evidence of socioeconomic differences in smoking and mortality (Mackenbach et al., 2008). People in lower social groups have a greater prevalence and intensity of smoking, a higher all-cause mortality rate and lower rates of cancer survival (Woods et al., 2006). The influence of smoking as a determinant of overall health inequalities is such that, if the entire population did not smoke, mortality differences between social groups would be halved (Jha et al., 2006).

Definition and comparability The proportion of daily smokers is defined as the percentage of the population aged 15 years and over who report smoking every day. International comparability is limited due to the lack of standardisation in the measurement of smoking habits in health interview surveys across EU member states. Variations remain in the age groups surveyed, wording of questions, response categories and survey methodologies, e.g. in a number of countries, respondents are asked if they smoke regularly, rather than daily.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

2.5. SMOKING AMONG ADULTS

2.5.1. Adult population smoking daily, 2010 and change in smoking rates, 2000-10 (or nearest year) 2010 (or nearest year)

Change 2000-10 Sweden Luxembourg Portugal Slovenia Finland Malta Slovak Republic Denmark Belgium Romania Netherlands United Kingdom Germany EU27 Italy Austria France Poland Czech Republic Cyprus Estonia Spain Hungary Lithuania Latvia Ireland Bulgaria Greece

14.0 18.0 18.6 18.9 19.0 19.2 19.5 20.0 20.5 20.5 20.9 21.5 21.9 23.0 23.1 23.2 23.3 23.8 24.6 25.9 26.2 26.2 26.5 26.5 27.9 29.0 29.2 31.9

-25.9 -30.8 -9.7 n.a. -18.8 n.a. -11.8 -34.4 -14.9 n.a. -27.0 -20.4 -11.3 -16.3 -5.3 -4.5 -13.7 -13.8 4.7 n.a. -13.5 -17.4 -12.3 -5.4 -33.6 -12.1 n.a. -8.9

Iceland Norway Switzerland Turkey

14.3 19.0 20.4 25.4

40 30 20 % of population aged 15 years and over

-37.6 -40.6 -29.4 -20.9

-50

-40

-30

-20

-10

0 10 % change over the period

Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Infobase.

1 2 http://dx.doi.org/10.1787/888932704000

2.5.2. Females and males smoking daily, 2010 (or nearest year) Males

Females

38 26

23 18 102

14 15

19 9

19 19

21 18

19 17

21 18 16

22 19 16

21 22

20 20

% of population aged 15 years and over 50

y ke

Tu r

nd la

it z

rw Sw

ed en n Lu m a Un xem r k i te bo ur d Ki g ng do Sl m o N e ven i th er a la nd Fi s nl an Be d lg iu m M al ta Fr an c e Sl Ge r ov ak man Re y pu b Po lic r tu ga Au l st ria EU 27 Cz ec h It al Re y pu bl ic Po la nd Ir e la nd Sp a Hu in ng ar Ro y m an i Es a to ni Cy a pr us Gr ee Bu c e lg a Li ria th ua ni a La tv ia

Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932704019

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

2.6. ALCOHOL CONSUMPTION AMONG ADULTS

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

Although adult alcohol consumption per capita gives useful evidence of long-term trends, it does not identify sub-populations at risk from harmful drinking patterns. Much of the burden of disease associated with alcohol consumption occurs among persons who have an alcohol dependence problem. The consumption of large quantities of alcohol at a single session, termed “binge drinking”, is also a particularly dangerous pattern of consumption (Institute of Alcohol Studies, 2007), which is on the rise in some countries and social groups, especially among young males (see Indicator 2.1 “Smoking and alcohol consumption among children”).

The EU region has the highest alcohol consumption in the world. Measured through monitoring annual sales data, it stands at 10.7 litres of pure alcohol per adult on average across EU member states, using the most recent data available (Figure 2.6.1). Leaving aside Luxembourg – because of the high volume of purchases by non-residents in this country – Austria, France, Latvia, Lithuania and Romania reported the highest consumption of alcohol, with 12.0 litres or more per adult in 2010. At the other end of the scale, southern European countries (Cyprus, Greece, Italy, Malta) along with Nordic countries (Iceland, Sweden, and Norway) have relatively low levels of consumption, in the region of 7-8 litres of pure alcohol per adult. Turkey and the Former Yugoslav Republic of Macedonia have rates well below four litres.

The 2006 Commission Communication on an EU strategy to support member states in reducing alcohol-related harm highlighted a number of priority themes, including protecting children and young people, reducing harm from alcohol-related road accidents, reducing the negative impact of alcohol in the workplace, education on harmful consumption, and developing a common alcohol evidence base at EU level (EC, 2009a). In 2010, the World Health Organization endorsed a global strategy to combat the harmful use of alcohol, through direct measures such as medical services for alcohol-related health problems, and indirect measures, such as policy options for restricting the availability and marketing of alcohol. This initiative was boosted in 2011 by the adoption of a new European Action Plan by the WHO Regional Office for Europe.

Although average alcohol consumption has gradually fallen in many European countries over the past three decades, it has risen in some others. There has been a degree of convergence in drinking habits across the European Union, with wine consumption increasing in many traditional beer-drinking countries and vice versa. The traditional wine-producing countries of Italy, France and Spain, as well as Greece, have seen their alcohol consumption per capita fall substantially since 1980 (Figures 2.6.1 and 2.6.2). On the other hand, alcohol consumption per capita in Cyprus, Finland, Iceland and Ireland rose by a quarter or more since 1980 although, in the case of Iceland and Cyprus, it started from a low level and therefore remains relatively low. Variations in alcohol consumption across countries and over time reflect not only changing drinking habits but also the policy responses to control alcohol use. Curbs on advertising, sales restrictions and taxation have all proven to be effective measures to reduce alcohol consumption (Bennett, 2003; WHO Europe, 2012a). Strict controls on sales and high taxation are mirrored by overall lower consumption in most Nordic countries.

Definition and comparability Alcohol consumption is defined as annual sales of pure alcohol in litres per person aged 15 years and over. The methodology to convert alcohol drinks to pure alcohol may differ across countries. Official statistics do not i ncl u d e u n re co rd e d a lco h o l consumption, such as home production. Italy reports consumption for the population 14 years and over, resulting in a slight underestimation, and Sweden for 16 years and over. In some countries (e.g. Luxembourg), national sales do not accurately reflect actual consumption by residents, since purchases by non-residents may create a significant gap between national sales and consumption.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

2.6. ALCOHOL CONSUMPTION AMONG ADULTS

2.6.1. Alcohol consumption among population aged 15 years and over, 2010 and change, 1980-2010 2010 (or nearest year)

Change per capita, 1980-2010 Italy Sweden Malta Greece Cyprus Netherlands Finland Bulgaria Poland United Kingdom Denmark Slovenia EU27 Slovak Republic Belgium Czech Republic Estonia Portugal Spain Hungary Germany Ireland France Austria Lithuania Romania Latvia Luxembourg

6.9 7.3 7.7 8.2 8.4 9.4 9.7 10.0 10.1 10.2 10.3 10.3 10.7 10.7 10.8 11.4 11.4 11.4 11.4 11.5 11.7 11.9 12.0 12.2 12.6 12.7 13.2 15.3

6.6 7.3 7.3 8.3 10.0 10.1

9 -38 35 -18 23 -10 -12 9 -12 -15 -26 -20 -3 -23 -38 -23 -16 24 -38 -16 17 1 12

Turkey FYR of Macedonia Norway Iceland Serbia Montenegro Switzerland Croatia

1.5 3.7

20 Litres per capita

-59

-17 10 70

-26

-75

-50

-25

50 75 % change over period

Source: OECD Health Data 2012; WHO Global Information System on Alcohol and Health.

1 2 http://dx.doi.org/10.1787/888932704038

2.6.2. Trends in alcohol consumption, selected EU countries, 1980-2010 Finland

France

Italy

Sweden

EU27

Alcohol consumption (litres per capita) 20

5 1980

1985

1990

1995

2000

2005

2010

Source: OECD Health Data 2012; WHO Global Information System on Alcohol and Health.

1 2 http://dx.doi.org/10.1787/888932704057

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

2.7. OVERWEIGHT AND OBESITY AMONG ADULTS

The growth in overweight and obesity rates among adults is a major public health concern. Obesity is a known risk factor for numerous health problems, including hypertension, high cholesterol, diabetes, cardiovascular diseases, respiratory problems (asthma), musculoskeletal diseases (arthritis) and some forms of cancer. Mortality also increases sharply once the overweight threshold is crossed (Sassi, 2010). Because obesity is associated with higher risks of chronic illnesses, it is linked to significant additional health care costs. Based on latest available data, more than half (52%) of the adult population in the European Union are overweight or obese. The prevalence of overweight and obesity among adults exceeds 50% in no less than 18 of 27 EU member states. Obesity – which presents even greater health risks than overweight – varies threefold among countries, from a low of around 8% in Romania (and Switzerland) to over 25% in Hungary and the United Kingdom, although some of the variations across countries may be due to different methodologies in data collection (Figure 2.7.1). On average across EU member states, 17% of the adult population is obese. There is little difference in the average obesity rate of men and women (Figure 2.7.1). However, there is some variation among individual countries, with more men than women being obese in Malta, Iceland and Norway, whereas a higher proportion of women are obese in Latvia, Turkey and Hungary. The largest disparities were in Latvia, whereas there was little, if any difference in male and female rates in the Czech Republic, Greece and the United Kingdom. The rate of obesity has doubled over the past 20 years in many European countries (Figure 2.7.2), regardless of previous levels. Obesity in 2010 is close to twice the rate of 1990 in both France and the United Kingdom, even though the rate in France is currently half that of the United Kingdom. The rise in obesity has affected all population groups, but to varying extents. Evidence from a number of countries, including Austria, England, France, Italy and Spain, indicates that obesity tends to be more common in disadvantaged socio-economic groups, and especially among women (Sassi et al., 2009). There is also a relationship between the number of years of education and obesity, with the most educated individuals displaying lower rates. Again, the gradient in obesity is stronger in women than in men (Sassi, 2010). A number of behavioural and environmental factors have contributed to the rise in overweight and obesity

rates in industrialised countries, including the widespread availability of energy dense foods and more time spent being physically inactive. Overweight and obesity have risen rapidly in children in recent decades, reaching double-figure rates in most countries (see Indicator 2.2 “Overweight and obesity among children”). Many countries have stepped up efforts to tackle the root causes of obesity, embracing increasingly comprehensive strategies and involving communities and key stakeholders. Better informed consumers, the availability of healthy food options, encouraging physical activity and a focus on vulnerable groups are some of the fields for action which have seen progress (EC, 2010a). There has also been a new interest in the use of taxes on foods rich in fat and sugar, with several governments (Denmark, Finland, France, Hungary) recently passing legislation aiming to change eating habits (OECD, 2012b).

Definition and comparability Overweight and obesity are defined as excessive weight presenting health risks because of the high proportion of body fat. The most frequently used measure is based on the body mass index (BMI), which is a single number that evaluates an individual’s weight in relation to height (weight/height2 , with weight in kilograms and height in metres). Based on the WHO classification (WHO, 2000), adults with a BMI from 25 to 30 are defined as overweight, and those with a BMI of 30 or over as obese. This classification may not be suitable for all ethnic groups, who may have equivalent levels of risk at lower or higher BMI. The thresholds for adults are not suitable to measure overweight and obesity among children. For most countries, overweight and obesity rates are self-reported through estimates of height and weight from population-based health interview surveys. The exceptions are the Czech and Slovak Republics, Hungary, Ireland, Luxembourg and the United Kingdom, where estimates are derived from health examinations. These differences limit data comparability. Estimates from health examinations are generally higher and more reliable than from health interviews.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

2.7. OVERWEIGHT AND OBESITY AMONG ADULTS

2.7.1. Prevalence of obesity among adults, 2010 (or nearest year) Self-reported data

Measured data

Males

7.9 10.3 11.4 11.5 12.8 12.9 12.9 13.4 13.8 14.7 15.4 15.6 15.6 15.8 16.0 16.6 16.8 16.9 16.9 16.9 17.3 19.7 21.0 22.5 22.9 23.0 26.1 28.5

Romania Italy Netherlands Bulgaria Austria France Sweden Denmark Belgium Germany Portugal Cyprus Finland Poland Spain EU27 Slovenia Estonia Latvia Slovak Republic Greece Lithuania Czech Republic Luxembourg Malta Ireland United Kingdom Hungary

8.0

Switzerland Norway Turkey Iceland

7.7

8.1 10.0 16.9 21.0

40 30 % of adult population

Females

7.6

9.6

11.1

12.6

10.2

11.3

11.6

13.2

12.4

13.4

12.4

13.1

12.6

13.1

13.7

14.4

13.1

13.8

15.7

16.1

14.6

14.5

16.7

15.5

15.7

15.2

16.6

14.7

17.3

16.6

16.5

16.3

17.3

16.8

17.0 20.9

12.0

16.7

17.1

17.3

19.2

20.6

21.0

23.6

21.1

24.7

24.0

22.0

26.1

26.2 30.4

26.3

8.6

8.0

11.0 21.0

13.2

19.3

22.7

30 40 % of adult population

Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Infobase.

1 2 http://dx.doi.org/10.1787/888932704076

2.7.2. Increasing obesity rates among adults in European countries, 1990, 2000 and 2010 (or nearest years) 2000

2010

21.0 5.4

7.5

6.0

7.7 8.1

10.0

12.4

13.2

14.0

16.3

18.2

21.0

23.0

23.1 22.9

22.5

20.4 19.7

17.4 11.3

14.2

16.9 11.9

15.1 16.9

16.0

14.1

15.6 8.4

6.8

11.2

12.3

12.6

15.6

15.4

14.7

12.8

11.5

13.4

12.1 13.8

12.9

9.5

5.5

5.8

5.5

9.0

8.5 9.1

9.2

12.9

12.8

12.4 11.5

11.4 9.4 6.1

8.6 10.3

8.6 7.9

16.9

26.1

28.5

1990

% 40

d an

ay rw

la er it z

y1 ng

d Un

i te

Ir e

ur bo

a ni ua

th Li

ic 1 bl pu Cz

Re ak ov Sl

a ni to Es

n ai Sp

d an

l ga

y an rm

r tu

m iu lg

k ar nm

ce an Fr

ria

ar lg

ly It a Ne

1. Hungary (1988, 2009), Ireland (2007), Luxembourg, the Slovak Republic (2008) and the United Kingdom figures are based on health examination surveys, rather than health interview surveys. Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Infobase.

1 2 http://dx.doi.org/10.1787/888932704095 HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

2.8. FRUIT AND VEGETABLE CONSUMPTION AMONG ADULTS

Nutrition is an important determinant of health. Inadequate consumption of fruit and vegetables is one factor that can play a role in increased morbidity. Proper nutrition assists in preventing a number of obesity-related chronic conditions, including cardiovascular disease, hypertension, Type 2 diabetes, stroke, certain cancers, musculoskeletal disorders and a range of mental health conditions. A European Commission White Paper advocated increasing the consumption of fruit and vegetables as one of a number of tools to offset a worsening trend of poor diets and low physical activity (EC, 2007). In response to a health survey question asking “How often do you eat fruit?”, the percentage of adults consuming fruit daily varied from 45% in Bulgaria and Romania, to 75% in Italy, Malta and Slovenia, and 84% in Switzerland around 2008 (Figure 2.8.1). Across the 19 EU member states providing data, an average 63% of adults ate fruit daily. Females ate fruit more often than males, with the largest gender differences in Denmark, the Slovak Republic and Germany (23, 20 and 19 percentage points respectively). In Mediterranean countries (Cyprus, Greece, Italy, Malta, Spain and Turkey), gender differences were much smaller, at under 10%. Among different age groups, older persons aged 65 and over were more likely to eat fruit, with consumption lowest among young people aged 15-24 years, except in Bulgaria and Romania, where young people ate the most (see also Indicator 2.3 “Fruit and vegetable consumption among children”). Fruit consumption also varies by socioeconomic status, generally being highest among persons with higher educational levels (Figure 2.8.3). However, this was not the case in Mediterranean countries (Cyprus, Malta, Spain, Greece), where lower educated persons ate fruit more often. Daily vegetable consumption ranged from around 50% in Estonia, Germany, Malta and the Slovak Republic to 75% in France and Slovenia, with Belgium and Ireland highest at 85% and 95% respectively (Figure 2.8.2). The average across 18 countries was the same as for fruit, 63%. Again, more females reported eating vegetables daily, except in Bulgaria and Ireland, where rates were similar. In the Czech and Slovak Republics, Germany, Italy, Malta and Spain, gender differences exceeded 10%. Patterns of vegetable consumption among age groups and educational groups are similar to those for fruit. Older persons more commonly ate vegetables daily, except in Bulgaria, the Czech Republic, Latvia and Romania. Highly educated persons ate vegetables more often, although the

difference between educational groups was small in Belgium, Cyprus, Italy, Greece, Slovenia and the Slovak Republic (Figure 2.8.4). Differences exceeded 20% in Bulgaria, Latvia and Romania. The availability of fruit and vegetables is the major determinant of consumption. Despite high variability between countries, vegetable and especially fruit availability is higher in southern European countries, with cereals and potatoes more available in central and eastern European countries. Fruit and vegetable availability also tends to be higher in families where household heads have a higher level of education (Elmadfa, 2009). The promotion of fruit and vegetable consumption, especially in schools and the workplace, features in the EU platform for action on diet, physical activity and health, a forum for European-level organisations, ranging from the food industry to consumer protection NGOs, willing to commit to tackling current trends in diet and physical activity (EC, 2011a). Policy makers and government representatives share ideas and best practice on the promotion of fruit and vegetable consumption in the High Level Group on Nutrition and Physical Activity.

Definition and comparability Estimates of daily fruit and vegetable consumption are derived from national and European Health Interview Survey questions, conducted in many EU member states between 2006 and 2010. Typically, respondents were asked “How often do you eat fruit (excluding juice)?” and “How often do you eat vegetables or salad (excluding juice and potatoes)?” Response categories included: Twice or more a day/ Once a day/Less than once a day but at least four times a week/Less than four times a week, but at least once a week/Less than once a week/Never. Data for France and Switzerland include juices, soups and potatoes. Data rely on self-report, and are subject to errors in recall. The same survey also asked for information on age, sex and educational level. Data are not age-standardised, with aggregate country estimates representing crude rates among respondents aged 15 years and over in all countries, except Germany which is 18 years and over.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

2.8. FRUIT AND VEGETABLE CONSUMPTION AMONG ADULTS

2.8.1. Daily fruit eating among adults, 2008 (or nearest year) Males

2.8.2. Daily vegetable eating among adults, 2008 (or nearest year)

Females

Slovenia

Males 82

Italy 69

Ireland

Czech Republic

Greece

Hungary

Romania

Denmark

Bulgaria

Romania

48 51 48 37

56 55

Turkey 60

Switzerland

53 51

Germany

Switzerland Turkey

59 59

Estonia

51 49

Malta

Slovak Republic

Bulgaria

Italy

Greece

Estonia

Poland

Cyprus

Poland

EU18 Czech Republic

Latvia

Belgium

Latvia 72

EU19

Spain

France

Cyprus

Germany

100 %

Slovenia

Spain

France

Slovak Republic

Belgium

Hungary

96 95

Ireland

Malta

Females

100 %

Source: Eurostat Statistics Database and national health interview surveys. 1 2 http://dx.doi.org/10.1787/888932704114

Source: Eurostat Statistics Database and national health interview surveys. 1 2 http://dx.doi.org/10.1787/888932704133

2.8.3. Daily fruit eating among adults, by educational level, 2008 (or nearest year)

2.8.4. Daily vegetable eating among adults, by educational level, 2008 (or nearest year)

Lowest educational level

Highest educational level

% 100

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

Source: Eurostat Statistics Database and national health interview surveys. 1 2 http://dx.doi.org/10.1787/888932704152

Highest educational level

ov Ge ak rm Re a n pu y bl M ic a Es lt a to ni a C z H It a e c un l y h g Re ar pu y bl Sp ic ai EU n Gr 17 Ro e e c m e a C y ni a p Bu r us lg a Po r i a la n La d Sl t v i ov a en Fr i a an Be ce lg iu m

nm Gr a r k e C y ece Bu pr u l s Ge gar rm ia Es any to Cz e c B e ni a Sl h l gi ov Re um a k pu Re bl pu ic bl E ic Ro U 1 m 8 an Sp i a Po a in la Fr nd an c M e Hu a l t ng a a La r y tv ia Sl It al ov y en ia T Sw u i t z r ke er y la nd

Lowest educational level

Sw Tu i t z r ke er y la nd

% 100

Source: Eurostat Statistics Database and national health interview surveys. 1 2 http://dx.doi.org/10.1787/888932704171

Health at a Glance: Europe 2012 ÂŠ OECD 2012

Chapter 3

Health care resources and activities

3.1.

Medical 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 (coronary angioplasty) . . . . . . . . . . . . . . . . . . . . . .

3.9.

Cataract surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.10. Hip and knee replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.11. Pharmaceutical consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.12. Unmet health care needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.1. MEDICAL DOCTORS

In many European countries, there are concerns about current or future shortages of doctors, in general or more specifically for certain categories of doctors or in certain locations (e.g. in rural and remote areas). This section provides data on the number of doctors per capita in European countries in 2010 and its evolution over the past decade, as well as a disaggregation between generalists and specialists. In 2010, Greece had, by far, the highest number of doctors per capita, with 6.1 doctors per 1 000 population, nearly twice the EU average of 3.4. Following Greece was Austria, with 4.8 doctors per 1 000 population. The number of doctors per capita was also relatively high in Norway, Portugal (although the number reported is an overestimation as it comprises all doctors licensed to practice, including some who may not be practising), Sweden, Switzerland and Spain. The number of doctors per capita was the lowest in Montenegro and Turkey, followed by Poland, Romania and Slovenia (Figure 3.1.1). Since 2000, the number of physicians per capita has increased in all European countries, except in France, Estonia and Poland. On average across EU member states, physician density grew from 2.9 doctors per 1 000 population in 2000 to 3.4 in 2010. The growth rate was particularly rapid in Greece, which started from the highest level in 2000, thereby increasing the gap with other countries, and the United Kingdom, which started from the second lowest level in 2000, thereby narrowing the gap with other European countries. In Greece, the number of doctors per capita has stabilised since the beginning of the crisis in 2008, following strong growth between 2000 and 2008. In the United Kingdom, the number of doctors per capita has gone up steadily over the past decade, from 2.0 doctors per 1 000 population in 2000 to 2.7 in 2010 (and 2.8 in 2011). The number of new registrations of foreigntrained doctors increased up to 2003 when it peaked at about 14 000, but has declined since then to about 5 000 in 2010 and 2011 (General Medical Council, 2012). At the same time, the number of new graduates from medical schools in the United Kingdom increased, from about 4 600 in 2003 to 5 800 in 2010 and in 2011, gradually exceeding the number of new registrations of foreign-trained physicians (OECD, 2012a). In France, the number of doctors per capita has not increased over the past decade, and it is expected to decrease until 2020, following the reduction in the number of new entrants and graduates from medical schools during the 1980s and 1990s (DREES, 2009).

In nearly all countries, the balance between generalist and specialist doctors has changed over the past few decades, with the number of specialists increasing much more rapidly. As a result, there are more specialists than generalists in most countries, except in Ireland, Malta, Portugal and Norway (Figure 3.1.2). This may be explained by a lesser interest in the traditional mode of practice of general practitioners (family doctors) given the workload and constraints attached to it. In addition, in many countries, the remuneration gap between generalists and specialists has widened (Fujisawa and Lafortune, 2008). The slow or negative growth in the number of generalists per capita raises concerns about access to primary care for certain population groups. In response to this shortage, many countries have taken steps to improve the number of training posts and attractiveness of general practice. For example, in France, the number of interns in general practice has increased markedly in recent years, with around half of all internships allocated to general practice in 2010 and 2011 (DREES, 2012). A number of countries are also considering the development of new roles for other health care providers, such as advanced practice nurses, to respond to growing demands for primary care (Delamaire and Lafortune, 2010).

Definition and comparability Practising physicians are defined as doctors who are providing care directly to patients. In some countries, the numbers also include doctors working in administration, management, academic and research positions (“professionally active” physicians), adding another 5-10% of doctors. Portugal reports all physicians entitled to practice, resulting in an even greater overestimation. Generalists include general practitioners (“family doctors”) and other generalist/non-specialist practitioners who may be working in hospitals or outside hospitals. Specialists include paediatricians, gynaecologists and obstetricians, psychiatrists, medical specialists, surgical specialists and other specialties. Other physicians include interns/residents if they are not reported in the field in which they are training, and doctors who are not classified elsewhere.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

3.1. MEDICAL DOCTORS

3.1.1. Practising doctors per 1 000 population, 2010 and change between 2000 and 2010 (or nearest year) 2010 (or nearest year)

Change 2000-10 (or nearest year) Greece 1 Austria Portugal 2 Sweden Spain Germany Lithuania Bulgaria Italy Czech Republic Denmark EU27 Slovak Republic1 Finland1 France 1 Estonia Ireland1 Malta Cyprus Belgium Netherlands1 Latvia Hungary Luxembourg United Kingdom Slovenia Romania Poland

6.1 4.8 3.8 3.8 3.8 3.7 3.7 3.7 3.7 3.6 3.5 3.4 3.3 3.3 3.3 3.2 3.1 3.1 3.0 2.9 2.9 2.9 2.9 2.8 2.7 2.4 2.4 2.2

3.8 3.6 2.8 2.8 2.7 2.1 1.7

2.1 2.3 n.a. 1.4 0.2 1.0 n.a. 0.6 2.0 1.4 n.a. 1.3 0.0 -0.1 n.a. n.a. 1.5 0.3 2.0 0.1 n.a. 2.6 3.3 1.2 2.1 -0.1

Norway Switzerland Iceland1 Serbia Croatia FYR of Macedonia1 Montenegro Turkey1

4.1

8 6 Per 1 000 population

3.5 2.2

2.8 n.a. 0.5 1.3 1.7 n.a. 1.1 3.0

-2

2 4 Average annual growth rate (%)

1. Data include not only doctors providing direct care to patients, but also those working in the health sector as managers, educators, researchers, etc. (adding another 5-10% of doctors). 2. Data refer to all doctors who are licensed to practice. Source: OECD Health Data 2012; Eurostat Statistics Database; WHO European Health for All Database.

1 2 http://dx.doi.org/10.1787/888932704190

3.1.2. Generalists and specialists as a share of all doctors, 2010 (or nearest year) Generalists1

Specialists 2

Medical doctors not further defined

67 33

73 18

rw ay Tu r k M ac ey ed on i C a Sw roat it z ia er la n Ic d el an d

la nd s rm an Be y lg iu Ro m m an i Fi a nl an d Au st ria Un i te EU d Ki 25 ng Lu d xe om m bo ur Es g to ni a It a De l y nm ar k Po la nd Sl ov en ia Cz ec L at vi h Re a pu bl i Li th c ua ni Bu a lg ar ia Sl ov S we ak de Re n pu b Hu lic ng ar y Gr ee ce

ce an th

r tu

ta al

la Ir e

77 20

76 21

79 21

64 36

57 43

% of total doctors 100

1. Generalists include general practitioners/family doctors and other generalist (non-specialist) medical practitioners. 2. Specialists include paediatricians, obstetricians/gynaecologists, psychiatrists, medical, surgical and other specialists. Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932704209

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

3.2. CONSULTATIONS WITH DOCTORS

Consultations with doctors can take place in doctors’ offices or clinics, in hospital outpatient departments or, in some cases, in patients’ own homes. In many European countries (e.g. Denmark, Italy, the Netherlands, Norway, Portugal, the Slovak Republic, Spain and the United Kingdom), patients are required or given incentives to consult a general practitioner (GP) about any new episode of illness. The GP may then refer them to a specialist, if indicated. In other countries (e.g. Austria, the Czech Republic and Iceland), patients may approach specialists directly. The number of doctor consultations per person per year is highest in Hungary, the Czech Republic and the Slovak Republic, while it is lowest in Cyprus, Malta and Sweden (Figure 3.2.1). The EU average is 6.3 consultations per person per year, with most member states reporting 4 to 7 visits per person per year. Cultural factors appear to play a role in explaining some of the variations across countries, although certain health system characteristics may also play a role. Some countries which pay their doctors mainly by fee-for-service tend to have aboveaverage consultation rates (e.g. Belgium and Germany), while other countries that have mostly salaried doctors tend to have below-average rates (e.g. Finland and Sweden). In Sweden, the low number of doctor consultations may also be explained partly by the fact that nurses play an important role in primary care (Bourgueil et al., 2006). Similarly, in Finland, nurses and other health professionals play an important role in providing primary care to patients in health centres, lessening the need for consultations with doctors (Delamaire and Lafortune, 2010). In many European countries, the average number of doctor consultations per person has increased since 2000 (Figure 3.2.1). This is consistent with the increase in the number of doctors per capita in most countries over the past decade (see Indicator 3.1). In the Czech Republic and the Slovak Republic, there has been a substantial reduction in the number of doctor consultations per capita over the past decade, although the number remains well above the EU average. In Spain also, there has been a marked decline in the number of doctor consultations per person since 2000. The number of doctor consultations varies not only across countries, but also among different population groups in each country. This is particularly the case for consultations with medical specialists. A recent OECD study, using health interview surveys carried out between 2006 and 2009, provides evidence on inequality in doctor consultations by income group in a number of European countries (Devaux and de Looper, 2012). Figure 3.2.2 shows the horizontal inequity index – a measure of inequality in health care use adjusted for differences in need – regarding the probability of having at least one visit to a generalist or a specialist during the year. The probability favours low income groups when it is below zero, and high income groups when it is above zero. The index is adjusted for differences in need for health care because health problems are more frequent and severe among lower income groups.

The probability of a generalist (GP) visit is equally distributed in most countries (Figure 3.2.2). When inequality does exist, it is often positive, indicating a pro-rich distribution, but the degree of inequality is small. Lower income people, however, consult a GP more frequently (results not shown). A different story emerges for specialist visits – in nearly all countries, high income people are more likely to see a specialist than those with low income (Figure 3.2.2), and also more frequently.

Definition and comparability Consultations with doctors refer to the number of contacts with physicians, including both generalists and specialists. There are variations across countries in the coverage of different types of consultations, notably in outpatient departments of hospitals. The data come mainly from administrative sources, although in some countries (Ireland, Italy, the Netherlands, Spain, Switzerland and the United Kingdom) the data come from health interview surveys. Estimates from administrative sources tend to be higher than those from surveys because of problems with recall and nonresponse rates. The figures for the Netherlands exclude contacts for maternal and child care. The data for Portugal exclude visits to private practitioners, which is also largely the case in Malta, while those for the United Kingdom exclude consultations with specialists outside hospital. In Luxembourg, doctors consultations outside the country are not included (these consultations account for a higher number than in other countries). In Germany, the data include only the number of cases of physicians’ treatment according to reimbursement regulations under the Social Health Insurance Scheme (a treatment only counts the first contact over a threemonth period, even if the patient consults a doctor more often). Telephone contacts are included in several countries (e.g. the Czech Republic, Ireland, Spain and the United Kingdom). The horizontal inequity indices shown here refer to the probability of a visit to a generalist or a specialist in a given year by income group. The data come from health interview surveys conducted between 2006 and 2009. Inequalities in doctor consultations are assessed in terms of household income. The number of doctor consultations is adjusted for need, based on self-reported information about health status. Differing survey questions and response categories may affect cross-national comparisons. The measures used to grade income can also vary. Caution is therefore needed when interpreting inequalities in doctor consultations across countries.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

3.2. CONSULTATIONS WITH DOCTORS

3.2.1. Doctors consultations per capita, 2010 and change between 2000 and 2010 (or nearest year) 2010 (or nearest year)

Change 2000-10 (or nearest year) Hungary Slovak Republic Czech Republic Germany Belgium Spain Lithuania Austria France Netherlands Poland Slovenia EU24 Estonia Luxembourg Latvia United Kingdom Romania Denmark Finland Portugal Ireland Malta Sweden Cyprus

11.7 11.3 11.0 8.9 7.7 7.5 6.9 6.9 6.7 6.6 6.6 6.4 6.3 6.0 6.0 5.6 5.0 4.7 4.6 4.3 4.1 3.8 2.9 2.9 2.1

7.3 6.3 6.2 5.2 4.4 4.0

-1.3 2.1 -0.3 -1.8 0.8 0.3 -1.1 1.1 1.1 n.a. 0.1 -0.5 -0.2 1.6 -0.6 -0.8 0.9 0.0 1.6 n.a. 1.7 0.4 0.7

Serbia Turkey Iceland Croatia Norway Montenegro Switzerland

8.1

12 9 Annual consultations per capita

0.5 -3.1

-0.9 n.a. 0.8 -1.2 n.a. 3.6 3.3

-4

-2

2 4 Average annual growth rate (%)

Source: OECD Health Data 2012; WHO European Health for All Database.

1 2 http://dx.doi.org/10.1787/888932704228

3.2.2. Inequity index for the probability of a visit in the past 12 months, adjusted for need, 2009 (or nearest year)

an Fr

n ai

ar nm

m iu

la Po

lg Be

a ni

it z

an nl Fi

ic bl

to Sw

ia Re

do ng

Ki d

i te

ec Cz

-0.05

0.05

ic S w Spa i t z in er la n Ir e d la nd Au st r Un B ia i te elg iu d Ki m ng do Hu m ng ar y Fr an ce S Sl ov lov en ak Re i a pu bl ic Po la nd Fi nl an Es d to ni a

0.10

Inequity index for specialist visits 0.15

Inequity index for GP visits 0.15

1. Visits in the past three months in Denmark. Source: Devaux and de Looper (2012).

1 2 http://dx.doi.org/10.1787/888932704247

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

3.3. NURSES

Nurses are usually the most numerous health profession, outnumbering physicians in most European countries. Nurses play a critical role in providing health care not only in traditional settings such as hospitals and long-term care institutions but increasingly in primary care (especially in offering care to the chronically ill) and in home care settings. However, there are concerns in many countries about shortages of nurses, and these concerns may well intensify in the future as the demand for nurses continues to increase and the ageing of the “baby boom” generation precipitates a wave of retirements among nurses. These concerns have prompted many countries to increase the training of new nurses combined with efforts to increase the retention of nurses in the profession (OECD, 2008a). In 2010, there were over 15 nurses per 1 000 population in Switzerland, Denmark and Belgium. Turkey had the fewest nurses, followed by Greece and the Former Yugoslav Republic of Macedonia (all these countries have fewer than four nurses per 1 000 population). The EU average was close to eight nurses per 1 000 population. Since 2000, the number of nurses per capita has increased in all European countries, except in Lithuania and the Slovak Republic. The increase was particularly large in Portugal, Spain and Turkey. In Denmark and France, there was also a fairly large increase in the number of nurses, rising by over 25% in absolute terms since 2000. In Estonia, the absolute number of nurses increased up to 2008, but has decreased since then; this has led to a reduction in the number of nurses per 1 000 population from 6.4 in 2008 to 6.1 in 2010. In 2010, the number of nurses per doctor ranged from more than four in Denmark, Finland, Ireland and Switzerland to less than one nurse per doctor in Greece and one in Italy and Turkey (Figure 3.3.2). The average across EU member states is two-and-a-half nurses per doctor, with many countries reporting between two to four nurses per doctor. In Greece and Italy, there is evidence of an oversupply of doctors and undersupply of nurses, resulting in an inefficient allocation of resources (OECD, 2009; Chaloff, 2008). A recent survey of nurses working in hospitals in 12 European countries provides evidence about their job satisfaction and intention to leave the profession, as well as their perception of the quality of care provided in their hospital. This survey found large variations in rates of job dissatisfaction among nurses, ranging from 11% in the Netherlands up to 56% in Greece, and their intention to leave their positions, with rates varying from 19% in the Netherlands up to almost 50% in Finland and Greece. Nurses in Greece also reported a particularly high level of burnout, and nearly half described their hospital wards as providing poor or fair quality of care only. In all countries,

higher nurse staffing levels and better work environments in hospital were significantly associated with better quality and safety of care for patients, and higher job satisfaction for nurses (Aiken et al., 2012). In response to shortages of general practitioners, some countries have taken the initiative to develop more advanced roles for nurses to ensure proper access to primary care. Evaluations of the experience with (advanced) nurse practitioners in Finland and the United Kingdom, as well as in Canada and the United States, show that they can improve access to care and reduce waiting times, while providing the same quality of care as doctors for patients with minor illnesses or those requiring routine follow-up. Most evaluations find a high patient satisfaction rate, with the impact on cost being either cost-reducing or costneutral. The development of new advanced roles for nurses requires the implementation of more advanced education and training programmes to ensure that they have proper skills (often at the master’s level at university), and also often involve legislative or regulatory changes to remove any barrier to the extension in their scope of practice (Delamaire and Lafortune, 2010).

Definition and comparability The number of nurses includes those employed in public and private settings, who are providing services directly to patients (“practising”) and/or are working as managers, educators or researchers (“professionally active”). Data for Belgium and Italy refer to all nurses who are licensed to practice, regardless of whether they are practising/professionally active or not (this is resulting in a large overestimation). In countries where there are different levels of nurses, the data include both “professional nurses” who have a higher level of education and perform higher level tasks and “associate professional nurses” who have a lower level of education but are nonetheless recognised and registered as nurses. Midwives, as well as nursing aids who are not recognised as nurses, are normally excluded. However, some countries include midwives because they are considered as specialist nurses. Austria reports only nurses working in hospitals, resulting in an underestimation. Data for Germany does not include about 270 000 nurses (representing an additional 30% of nurses) who have three years of education and are providing services for the elderly.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

3.3. NURSES

3.3.1. Practising nurses per 1 000 population, 2010 and change between 2000 and 2010 2010 (or nearest year)

Change 2000-10 (or nearest year) Denmark Belgium1 Ireland 2 Germany Luxembourg Sweden United Kingdom Finland France 2 Netherlands Slovenia Czech Republic EU27 Austria 3 Lithuania Malta Italy1 Hungary Estonia Slovak Republic 2 Portugal 2 Poland Romania Spain Cyprus Latvia Bulgaria Greece 2

15.4 15.1 13.1 11.3 11.1 11.0 9.6 9.6 8.5 8.4 8.2 8.1 7.9 7.7 7.0 6.5 6.3 6.2 6.1 6.0 5.7 5.3 5.2 4.9 4.9 4.7 4.2 3.3

14.5 14.4 5.8 5.3 5.1 3.6 1.6

1.0 1.6 n.a. 1.2 n.a. 0.4 2.4 1.2 1.8 0.6 1.2 0.7 -0.9 n.a. 1.2 1.7 0.3 -2.1 5.0 0.7 n.a. 3.2 1.5 0.3 0.9 2.2

Switzerland Iceland 2 Norway Serbia Croatia Montenegro FYR of Macedonia 2 Turkey2

16.0

20 15 Per 1 000 population

2.5 n.a

2.2 0.9 2.2 1.1 1.4 0.3 2.4 4.2

-3

3 6 Average annual growth rate (%)

1. Data refer to all nurses who are licensed to practice. 2. Data include not only nurses providing direct care to patients, but also those working in the health sector as managers, educators, researchers, etc. 3. Austria reports only nurses employed in hospitals. Source: OECD Health Data 2012; Eurostat Statistics Database; WHO European Health for All Database.

1 2 http://dx.doi.org/10.1787/888932704266

3.3.2. Ratio of nurses to physicians, 2010 (or nearest year) 6

5 4.4

4.3

4.2

4.2 4.0

4.0 3.5

3.5

3.4 3.1

4.0

3.0

2.9 2.6

2.5

2.4

2.5 2.3

2.2

2.1 1.9

1.9

2.0 1.8

1.6

1.5

1.3

1.9 1.4

1.1

1.0

1.0 0.5

nm De

ar nl k an d1 N e Ir e th lan e d Lu r lan Un xem d s 1 i te b d ou Ki rg ng d Sl om ov e B e ni a lg iu Ge m 1 rm a Sw ny ed e Fr n an ce EU 27 Cz ec Pol h a Re nd pu Ro b l i c m a Hu ni a ng ar y M al t Es a to Sl L i t ni a ov hu ak a Re ni a pu bl C y ic pr u Au s st ria La t Po v i a r tu ga l Sp Bu a in lg ar ia It a ly 1 Gr ee ce Sw it z er la n Ic d el an N d M or w on te ay ne gr Se o FY rb R i o f Cr o a M ac atia ed on i Tu a rk ey

1. For those countries which have not provided data for practising nurses and/or practising physicians, the numbers relate to the same concept (“professionally active” or “licensed to practice”) for both nurses and physicians, for the sake of consistency. Source: OECD Health Data 2012; Eurostat Statistics Database; WHO European Health for All Database.

1 2 http://dx.doi.org/10.1787/888932704285 HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

3.4. MEDICAL TECHNOLOGIES: CT SCANNERS AND MRI UNITS

New medical technologies are improving diagnosis and treatment, but they are also increasing health spending. This section presents data on the availability and use of two diagnostic technologies: computed tomography (CT) scanners and magnetic resonance imaging (MRI) units. CT scanners and MRI units help physicians diagnose a range of conditions by producing images of internal organs and structures of the body. Unlike conventional radiography and CT scanning, MRI exams do not expose patients to ionising radiation. The availability of CT scanners and MRI units has increased rapidly in most European countries over the past two decades. For example, in the Netherlands, the number of MRI units per capita was multiplied by ten between 1990 and 2010, while the number of CT scanners nearly doubled. Similarly, in Italy, the number of MRI scanners per capita was increased by nearly six times between 1997 and 2010, and the number of CT scanners more than doubled. In 2010, Greece, Italy and Cyprus had the highest number of MRI and CT scanners per capita among EU member states. Iceland and Switzerland also had significantly more MRI and CT scanners than the EU average (Figures 3.4.1 and 3.4.2). The numbers of MRI units and CT scanners per population were the lowest in Hungary and Romania. There is no general guideline or benchmark regarding the ideal number of CT scanners or MRI units per population. However, if there are too few units, this may lead to access problems in terms of geographic proximity or waiting times. If there are too many, this may result in an overuse of these costly diagnostic procedures, with little if any benefits for patients. Data on the use of these diagnostic scanners are available only for a smaller group of countries. Based on this more limited country coverage, the number of CT and MRI exams per capita is the highest in Greece, consistent with the fact that Greece also has the highest number of these two types of scanners. The number of MRI exams per capita is also above average in Germany and Luxembourg, as well as in Iceland and Turkey. It is the lowest in Ireland and Slovenia, although in these two countries only CT exams and MRI exams carried out in hospitals are reported, resulting in an underestimation.

In Greece, most CT and MRI scanners are installed in privately-owned diagnostic centres and only a minority are found in public hospitals. While there are no guidelines regarding the use of CT and MRI scanners in Greece (Paris et al., 2010), since late 2010, a ministerial decree has established certain criteria concerning the purchase of imaging equipment in the private sector (Official Gazette, No. 1918/10, December 2010). One of the main criteria is based on a minimum threshold of population density (30 000 population for CT scanners and 40 000 for MRIs). These regulations do not apply to the public sector. Clinical guidelines have been developed in some European countries to promote a more rational use of such diagnostic technologies (OECD, 2010b). In the United Kingdom, since the creation of the Diagnostic Advisory Committee by the National Institute for Health and Clinical Excellence (NICE), a number of guidelines have been issued on the appropriate use of MRI and CT exams for different purposes (NICE, 2012).

Definition and comparability For MRI units and CT scanners, the numbers of equipment per million population are reported. MRI exams and CT exams relate to the number of exams per 1 000 population. In most countries, the data cover equipment installed both in hospitals and the ambulatory sector. However, there is only partial coverage for some countries. MRI units and CT scanners outside hospitals are not included in some countries (Belgium, Germany and Spain, as well as Switzerland for MRI units). For the United Kingdom, the data only include scanners in the public sector. MRI and CT exams outside hospitals are not included in certain countries (Austria, Ireland, Slovenia, Spain and the United Kingdom). Furthermore, MRI and CT exams for Ireland only cover public hospitals. The Netherlands only report data on publicly-financed exams.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

3.4. MEDICAL TECHNOLOGIES: CT SCANNERS AND MRI UNITS

3.4.1. MRI units, 2010 (or nearest year) Hospital

Outside hospital

Greece Italy Cyprus Finland Austria Denmark Luxembourg Ireland Netherlands Spain1 Belgium1 EU23 Germany1 Portugal Estonia Latvia Malta France Slovak Republic Czech Republic United Kingdom 2 Poland Lithuania Slovenia Bulgaria Hungary Romania

3.4.2. CT scanners, 2010 (or nearest year)

Total (no breakdown)

Hospital 22.6

22.4 19.9 18.7 18.6 15.4 13.8 12.5 12.2 10.7 10.7 10.3 10.3 9.2 8.2 7.6 7.2 7.0 6.8 6.3 5.9 4.7 4.6 4.4 4.1 3.0 2.4

Iceland Switzerland1 Turkey Croatia

22.0 17.8 9.5 7.2

Outside hospital

Greece Cyprus Italy Malta Austria Bulgaria Denmark Portugal Latvia Luxembourg Finland EU23 Germany1 Lithuania Estonia Ireland Spain1 Czech Republic Poland Slovak Republic Belgium1 Slovenia Netherlands France United Kingdom 2 Hungary Romania

34.3 33.6 31.6 31.3 29.8 29.7 27.6 27.4 27.2 25.6 21.1 20.4 17.7 17.7 15.7 15.6 15.0 14.5 14.3 13.8 13.2 12.7 12.3 11.8 8.2 7.3 5.8

Iceland Switzerland Croatia Turkey

20 25 Per million population

Total (no breakdown)

37.7 32.6 15.8 12.4

32 40 Per million population

Note: The EU average does not include countries which only report equipment in hospital. 1. Equipment outside hospital is not included. 2. Any equipment in the private sector is not included.

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932704304

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932704323

3.4.3. MRI exams, 2010 (or nearest year)

3.4.4. CT exams, 2010 (or nearest year)

Hospital

Outside hospital

Greece Germany Luxembourg France Denmark Belgium Netherlands Estonia Austria1 Spain1 United Kingdom1 Czech Republic Slovak Republic Hungary2 Ireland1 Slovenia1

Hospital

Total (no breakdown) 97.9 95.2 79.6 60.2 57.5 52.8 49.1 48.1 47.6 45.6 40.8

33.5 33.2 31.7 17.3 2.0

Turkey Iceland

79.5 74.2

80 100 Per 1 000 population

Outside hospital

Greece Estonia Luxembourg Belgium Austria1 France Germany Denmark Slovak Republic Czech Republic Spain1 United Kingdom1 Hungary2 Ireland1 Netherlands Slovenia1

Total (no breakdown) 320.4 275.4 188.0 179.3 145.5 145.4

117.1 105.2 89.2 86.5 82.8 76.4 76.2 75.4 66.0 12.8

Iceland Turkey

159.8 103.5

140

1. Exams outside hospital are not included. 2. Exams in hospital are not included.

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704342

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

210

280 350 Per 1 000 population

1 2 http://dx.doi.org/10.1787/888932704361

3.5. HOSPITAL BEDS

The number of hospital beds provides an indication of the resources available for delivering services to inpatients in hospitals. This section presents data on the total number of hospital beds, including those allocated for curative care, psychiatric care, long-term care and other types of care. It does not capture the capacity of hospitals to provide sameday emergency or elective interventions. Over the past ten years, the number of hospital beds per population has decreased in all European countries, except Greece and Turkey. On average across EU member states, the number fell by close to 2% per year, coming down from 6.5 beds per 1 000 population in 2000 to 5.3 in 2010 (Figure 3.5.1). This reduction in the number of hospital beds has been accompanied by a reduction in average length of stays (Indicator 3.7) and, in some countries, a reduction in hospital admissions and discharges (Indicator 3.6). The reduction in the number of hospital beds has been particularly pronounced in Latvia (coming down from 8.7 beds per 1 000 population in 2000 to 5.3 in 2010), Estonia, Italy and Norway. In all countries, progress in medical technologies has enabled a move to same-day surgery and a reduced need for long hospitalisation. In many countries, the financial and economic crisis which started in 2008 also provided a further stimulus to reduce hospital capacity as part of policies to reduce public spending on health (European Observatory on Health Systems and Policies, 2012). For example, in Ireland, policies to reduce costs in the hospital sector in the aftermath of the crisis included a reduction in hospital beds, and incentives to reduce the length of stays in hospitals and increase day care (Thomas and Burke, 2012). In 2010, Austria and Germany had the highest number of hospital beds per capita, with around eight beds per 1 000 population (Figure 3.5.1). The high supply of hospital beds in these two countries is associated with a large number of hospital admissions/discharges, as well as long average length of stays in Germany. Turkey had the lowest number of beds per capita, although their number increased markedly over the past decade. Ireland, Sweden and the United Kingdom also have a relatively low number of hospital beds (although the data in the United Kingdom and Ireland do not include beds in private hospitals). More than two-thirds of hospital beds are allocated for curative care on average across EU member states (Figure 3.5.2). The rest of the beds are allocated for psychiatric care (15%), long-term care (8%) and other types of care (8%). However, in some countries, the share of beds allocated for psychiatric care and long-term care is much greater than the average. In Finland, a greater share of hospital beds is allocated for long-term care (32%) than for curative care (30%), because local governments (municipalities) use some beds in health care centres (which are defined as hospitals) for providing some institution-based long-term care (OECD, 2005).

The share of beds in private for-profit hospitals has increased in some countries over the past decade. In Germany, the share increased from 23% of all beds in 2002 to 30% in 2010, accompanied by a decrease in the share of beds in public hospitals from 45% to 41%. The remaining beds were in private not-for-profit hospitals (whose share also declined slightly). In France, the share of beds in private for-profit hospitals also increased during the past decade but to a lesser extent, from 20% in 2000 to 23% in 2010, while the proportion of beds in public hospitals decreased from 66% in 2000 to 63% in 2010 (OECD, 2012a). In several countries, the reduction in the overall number of hospital beds has been accompanied by an increase in their occupancy rates. Since 2000, the occupancy rate of curative care beds increased significantly in Ireland (from 85% in 2000 to 91% in 2010), Norway (from 85% to 93%) and Switzerland (from 85% to 88%) (OECD, 2012a).

Definition and comparability Hospital beds are defined as all beds that are regularly maintained and staffed and are immediately available for use. They include beds in general hospitals, mental health and substance abuse hospitals, and other specialty hospitals. Beds in nursing and residential care facilities are excluded. Curative care beds are beds accommodating patients where the principal intent is to do one or more of the following: cure physical illness or provide definitive treatment of injury, perform surgery, relieve symptoms of physical illness or injury (excluding palliative care), reduce severity of physical illness or injury, protect against exacerbation and/or complication of physical illness and/or injury which could threaten life or normal functions, perform diagnostic or therapeutic procedures, manage labour (obstetric). Psychiatric care beds are beds accommodating patients with mental health problems. They include beds in psychiatric departments of general hospitals, and all beds in mental health and substance abuse hospitals. Long-term care beds are hospital beds accommodating patients requiring long-term care due to chronic impairments and a reduced degree of independence in activities of daily living. They include beds in long-term care departments of general hospitals, beds for long-term care in specialty hospitals, and beds for palliative care. Data for some countries do not cover all hospitals. In Ireland and the United Kingdom, data are restricted to public or publicly-funded hospitals only.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

3.5. HOSPITAL BEDS

3.5.1. Hospital beds per 1 000 population, 2010 and change between 2000 and 2010 2010 (or nearest year)

Change 2000-10 (or nearest year) Germany Austria Hungary Czech Republic Lithuania Poland Bulgaria Belgium France Slovak Republic Romania Finland Luxembourg Estonia Latvia EU27 Greece Netherlands Slovenia Malta Cyprus Italy Denmark Portugal Spain Ireland United Kingdom Sweden

8.3 7.6 7.2 7.0 6.8 6.6 6.5 6.4 6.4 6.4 6.3 5.9 5.4 5.3 5.3 5.3 4.9 4.7 4.6 4.5 3.7 3.5 3.5 3.4 3.2 3.1 3.0 2.7

5.6 5.4 5.0 4.6 3.9 3.3 2.5

-0.4 -1.4 -1.0 -2.7 n.a. -1.3 n.a. -2.1 -2.0 -2.0 -2.5 n.a. -2.9 -4.8 -1.9 0.3 n.a. -1.7 n.a. -2.1 -2.9 -2.0 -1.1 -1.5 n.a. n.a. -2.0

Iceland Croatia Serbia Switzerland FYR of Macedonia Montenegro Norway Turkey

5.8

10 8 Per 1 000 population

-1.0

n.a. -0.7 -1.4 -2.3 -1.0 -1.0 -3.3 2.3

-6

-3

0 3 Average annual growth rate (%)

Source: OECD Health Data 2012; Eurostat Statistics Database; WHO European Health for All Database.

1 2 http://dx.doi.org/10.1787/888932704380

3.5.2. Hospital beds by function of health care, 2010 (or nearest year) Countries ranked from highest to lowest number of total hospital beds per capita Curative care beds

% 100

Psychiatric care beds

Long-term care beds

Other hospital beds

60 96

40 72

69 58

74 66

74 64

78 69

81 66

80 73

74 63

20 31

C Sw roa it z tia er of M lan ac d ed on i No a rw ay Tu rk ey R FY

ua ni Po a la n Bu d lg ar Be ia lg iu m Sl ov Fr ak an Re c e pu b Ro l i c m an i F a L u inl a xe nd m bo ur Es g to ni a La tv ia EU 27 G Ne ree c th er e la nd s Sl ov en ia M al ta Cy pr us It De al y nm a Po r k r tu ga l Sp ai n Un i t e Ir e l a d K i nd ng do Sw m ed en

ria

an rm

Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932704399

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

3.6. HOSPITAL DISCHARGES

Hospital discharges measure the number of people who were released after staying at least one night in hospital. Together with the average length of stay, they are important indicators of hospital activities. Hospital activities are affected by a number of factors, including the capacity of hospitals to treat patients, the ability of the primary care sector to prevent avoidable hospital admissions, and the availability of post-acute care settings to provide rehabilitative and long-term care services. In 2010, hospital discharge rates were the highest in Austria, Bulgaria, Germany and Romania (Figure 3.6.1). They were the lowest in Cyprus, Portugal and Spain as well as in the Former Yugoslav Republic of Macedonia. In general, countries that have a greater number of hospital beds also tend to have higher discharge rates. For example, the number of hospital beds per capita in Austria and Germany is more than two-times greater than in Portugal and Spain, and discharge rates are also more than twotimes greater (see Indicator 3.5). Trends in hospital discharge rates over the past decade vary widely across EU member states. In about one-third of EU member states (including Austria, Bulgaria, Germany, Greece, Poland and Romania), discharge rates have increased between 2000 and 2010. In a second group of countries (including the Czech Republic, Denmark, Slovenia, Sweden and the United Kingdom), they have remained stable, while in the third group (including Finland, France, Hungary, Italy and Luxembourg), discharge rates fell between 2000 and 2010. Trends in hospital discharges may reflect several factors that are not easily disentangled. Demand for hospitalisation may grow as populations age, given that older people account for a disproportionately high percentage of hospital discharges in all countries. For example, in Austria and Germany, over 40% of all hospital discharges in 2010 were for people aged 65 and over, more than twice their share of the population (17.6% and 20.7% respectively). However, population ageing alone may be a less important factor in explaining trends in hospitalisation rates than changes in medical technologies and clinical practices. A significant body of research shows that the diffusion of new medical interventions gradually extends to older population groups, as interventions become safer and more effective for people at older ages (e.g. Dormont and Huber, 2006). However, the diffusion of new medical technologies may also involve a reduction in hospitalisation if it entails a shift from procedures requiring overnight stays in hospitals to same-day procedures. In the group of countries

where discharge rates have decreased over the past decade, the reduction can be explained at least partly by a strong rise in the number of day surgeries (see Indicator 3.9, for example, for evidence on the rise in day surgeries for cataracts). Lithuania has the highest discharge rate for circulatory diseases, followed by Bulgaria and Germany (Figure 3.6.2). The high rates in Bulgaria and Lithuania are associated with high mortality rates from circulatory diseases, which may be used as a proxy indicator for the occurrence of these diseases (see Indicator 1.4). But Germany does not have high mortality rates for circulatory diseases, suggesting that different clinical practices may play a role in explaining high discharge rates. Austria and Germany have the highest discharge rates for cancer, followed by Hungary (Figure 3.6.3). While the high rate in Hungary is associated with a high mortality rate from cancer (which may also be used as a proxy for the occurrence of the disease; see Indicator 1.5), this is not the case for Austria and Germany. In Austria, the high rate is associated with a high rate of hospital readmissions for further investigation and treatment of cancer patients (EC, 2008a).

Definition and comparability Discharge is defined as the release of a patient who has stayed at least one night in hospital. It includes deaths in hospital following inpatient care. Same-day separations are usually excluded, with the exception of Norway, Poland, the Slovak Republic and Turkey which include some same-day separations. Healthy babies born in hospitals are excluded completely (or almost completely) from hospital discharge rates in several countries (e.g. Austria, Cyprus, Estonia, Finland, Greece, Ireland, Latvia, Luxembourg, Spain, Turkey). These comprise 3-7% of all discharges. Data for some countries do not cover all hospitals. In Denmark, Ireland and the United Kingdom, data are restricted to public or publicly-funded hospitals only. Data for Portugal relate only to public hospitals on the mainland. Data for Austria, Estonia, Luxembourg and the Netherlands include only acute care/short-stay hospitals.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

3.6. HOSPITAL DISCHARGES

3.6.1. Hospital discharges per 1 000 population, 2000 and 2010 (or nearest year) 2000

2010

141

129

158 142

172

169

175

102

116

112

132

128

136

132

149

144

163

150

156

169

172

178

176

185

182

195

200

192

212

203

237

224

240

261

250

254

Per 1 000 population 300

100

rw a Cr y 2 Sw oa it z tia er la n Se d rb Tu ia rk ey 1 ,2 Ic F Y Mo el a R n t nd of en M eg ac ro ed on ia

Au st r Bu i a 1 lg a Ge r ia rm Ro a n y m an Sl ov L i t h i a ak ua Re ni a pu bl Po ic 2 la n Cz G d2 ec re ec h Re e 1 pu b Hu lic ng a Fi r y nl an Be d 1 lg iu m EU 2 De 4 nm a Es rk to ni a Fr 1 an c Sw e ed Sl en Lu ov xe en m ia bo ur Un g1 i te L a t d Ki via 1 ng do m M al Ir e t a la nd 1 Ne It th al y er la n Po ds r tu ga Sp l ai Cy n 1 pr us 1

1. Excludes discharges of healthy babies born in hospital (between 3-7% of all discharges). 2. Includes same-day discharges. Source: OECD Health Data 2012; Eurostat Statistics Database; WHO European Health for All Database.

1 2 http://dx.doi.org/10.1787/888932704418

3.6.2. Hospital discharges for circulatory diseases per 1 000 population, 2010 (or nearest year) Lithuania Bulgaria Germany Romania Slovak Republic Austria Estonia Hungary Poland Greece Finland Latvia Czech Republic EU27 Sweden Belgium Slovenia Italy Denmark Luxembourg France Netherlands Malta Portugal Spain United Kingdom Ireland Cyprus

3.6.3. Hospital discharges for cancers per 1 000 population, 2010 (or nearest year) 45

38 36 33 33 33 32 30 29 28 27 27 27 24 23 21 20 20 20 20 19 17 13 13 13 13 12 8

Norway Croatia Switzerland Turkey FYR of Macedonia Iceland

19 15 14 14

45 Per 1 000 population

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932704437

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

29 25 23 20 20 19 18 17 17 17 17 16 15 15 14 14 13 13 12 12 12 11 11 10 9 8 8 5

Croatia Norway Switzerland Iceland FYR of Macedonia Turkey

24 20

Austria Germany Hungary Romania Greece Slovak Republic Poland Slovenia Lithuania Finland Estonia Bulgaria Czech Republic EU27 Luxembourg Denmark Latvia Sweden Italy Belgium France Portugal Netherlands Spain United Kingdom Malta Ireland Cyprus

19 16 14 12 12 9

30 Per 1 000 population

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932704456

3.7. AVERAGE LENGTH OF STAY IN HOSPITALS

The average length of stay in hospitals is often regarded as an indicator of efficiency, since a shorter stay may reduce the cost per discharge and shift care from inpatient to less expensive post-acute settings. However, shorter stays tend to be more service intensive and more costly per day. Too short a length of stay could also have adverse effects on health outcomes, or reduce the comfort and recovery of the patient. If this leads to a rising readmission rate, costs per episode of illness may fall little, or even rise. In 2010, the average length of stay in hospitals was the lowest in Turkey, Norway and Denmark (Figure 3.7.1). It was the highest in Finland, followed by the Former Yugoslav Republic of Macedonia, Croatia, Switzerland and Germany. The high average length of stay in Finland is due to a large proportion of beds allocated for convalescent patients and long-term care (see Indicator 3.5). Focusing only on stays in acute care units, the average length of stay in Finland is not greater, indeed is even lower than in most other European countries. The average length of stay in hospitals has decreased over the past decade in all European countries, falling from 8.2 days in 2000 to 6.9 days in 2010 on average in EU member states (Figure 3.7.1). The reduction in average length of stay was particularly marked in Bulgaria, Croatia, the Former Yugoslav Republic of Macedonia and Switzerland. It also decreased in the Netherlands and the United Kingdom. Several factors explain this general decline, including the use of less invasive surgical procedures, changes in hospital payment methods, and the expansion of early discharge programmes enabling patients to return to their home to receive follow-up care. A growing number of countries (e.g. France, Germany, Poland) have moved to prospective payment methods often based on diagnosis-related groups (DRGs) to set payments based on the estimated cost of hospital care for different patient groups in advance of service provision. These payment methods have the advantage of encouraging providers to reduce the cost of each episode of care (OECD, 2010b). In Switzerland, the move from per diem payments to diagnosis-related groups (DRG) based payments has contributed to the reduction in length of stay in those cantons that have modified their payment system (OECD and WHO, 2011). In the Netherlands, the introduction of a new payment system for hospitals in 2006 also provided incentives to reduce length of stay. Prior to the reform, hospitals were paid

on a fixed amount per bed and beddays. Since 2006, a growing share of hospital payments is determined through negotiations between insurers and hospitals, based on the Dutch version of DRGs (Westert and Klazinga, 2011). While the average length of stay in hospitals in the Netherlands used to be above the EU average in 2000, it has now fallen below. Still, a number of additional interventions have been identified by hospital staff to further reduce length of stay in Dutch hospitals, including a further increase in the share of same-day surgery, reducing waiting times for examinations, implementing acute stroke units, and promoting early discharge planning and follow-up (Borghans et al., 2012). Focusing on average length of stay for specific diseases or conditions can remove some of the heterogeneity that may arise from the different mix and severity of conditions across countries. Figure 3.7.2 shows that the average length of stay for a normal delivery ranges from less than two days in Turkey, Iceland, the United Kingdom and the Netherlands, to five days or more in the Slovak Republic, Romania, Croatia and Switzerland. The length of stay for a normal delivery has become shorter in nearly all countries over the past decade, dropping from five days in 2000 to about three-anda-half days in 2010 on average in EU member states. Lengths of stay following acute myocardial infarction (AMI, or heart attack) also declined over the past ten years. In 2010, it was the lowest in Denmark, Norway and Turkey, at four days or less. At the other end of the scale, it was highest in Estonia, Germany, Lithuania and Croatia, at over nine days (Figure 3.7.3). In this latter group of countries, long average length of stays may be due to the fact that some patients originally admitted for AMI are no longer receiving acute care, but nonetheless stay in hospitals for a certain period to receive post-acute care.

Definition and comparability 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.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

3.7. AVERAGE LENGTH OF STAY IN HOSPITALS

3.7.1. Average length of stay in hospital for all causes, 2000 and 2010 (or nearest year) 2000

9.6

5.8

8.1

9.0

9.9

9.8

4.1

4.5

4.6

5.7

5.1

5.7

5.8

5.7

6.0

5.9

6.1

6.6

6.3

6.8

6.7

7.0

6.9

7.0

7.3

7.1

7.5

7.9

7.7

8.1

8.0

9.5

2010

11.6

Days 15

Fi nl Ge and rm a Be ny lg i L i um th ua ni Un i te L a a d t Ki via Lu ngd xe om m bo Sl Ro ur g ov m ak a C z Re ni a e c pu h Re blic pu bl Es ic to n Gr i a ee ce EU 25 Sp ai n M al ta It a Au l y st Sl r i a ov en Ir e i a la Bu nd lg ar Po i a la Po nd Ne r tu th ga er l la nd Cy s pr u Fr s an Sw ce ed Hu en ng De ar y nm FY ar R k of M ac ed on Cr i a Sw oa it z tia er la nd M S er on bi te a ne gr Ic o el an No d rw a Tu y rk ey

Source: OECD Health Data 2012; Eurostat Statistics Database; WHO European Health for All Database.

1 2 http://dx.doi.org/10.1787/888932704475

3.7.2. Average length of stay for normal delivery, 2010 (or nearest year) Slovak Republic Romania Cyprus Czech Republic Hungary Belgium France Bulgaria Luxembourg Austria Greece Poland Slovenia Latvia Lithuania EU26 Italy Finland Germany Denmark Portugal Malta Spain Sweden Ireland Netherlands United Kingdom

3.7.3. Average length of stay for acute myocardial infarction (AMI), 2010 (or nearest year)

5.3 5.0 4.6 4.6 4.5 4.3 4.3 4.2 4.1 4.0 4.0 4.0 4.0 3.7 3.7 3.6 3.5 3.1 3.1 2.7 2.7 2.7 2.5 2.3 2.0 1.9 1.8

Croatia Switzerland FYR of Macedonia Norway Iceland Turkey

5.4 5.0 4.7 3.1 1.8 1.5

6 Days

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932704494

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

Germany Lithuania Estonia Finland Ireland Portugal Romania Spain United Kingdom Italy Slovenia Belgium Malta Austria Latvia EU27 Cyprus Greece Netherlands Czech Republic France Hungary Luxembourg Poland Bulgaria Sweden Slovak Republic Denmark

10.6 9.4 9.1 8.1 8.0 7.9 7.9 7.8 7.8 7.7 7.7 7.6 7.6 7.2 7.1 7.1 7.1 7.0 6.5 6.4 6.2 5.9 5.9 5.7 5.1 4.7 4.6 3.9

Croatia Switzerland FYR of Macedonia Iceland Norway Turkey

10.2 7.9 7.1 6.8 4.0 4.0

12 Days

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932704513

3.8. CARDIAC PROCEDURES (CORONARY ANGIOPLASTY)

Heart diseases are a leading cause of hospitalisation and death in European countries (see Indicator 1.4). Coronary angioplasty is a procedure that has revolutionised the treatment of ischemic heart diseases over the past twenty years, involving the use of a minimally invasive technique to re-open the obstructed coronary arteries rather than an open-chest bypass surgery. The placement of a stent to keep the artery open accompanies the majority of angioplasties. There is considerable variation across European countries in the use of coronary angioplasty (Figure 3.8.1). Germany, Belgium and Austria had the highest rates of angioplasty in 2010, although the rates in these three countries are overestimated because they are based on a count of all procedures rather than based on a count of patients (see the box on “Definition and comparability”). The angioplasty rate was the lowest in Ireland, Poland, Romania and the United Kingdom. However, in these latter two countries, the data do not cover activities in private hospitals, resulting in some underestimation. The use of angioplasty has increased rapidly since 1990 in most European countries, overtaking coronary bypass surgery as the preferred method of revascularisation around the mid-1990s – about the same time that the first published trials of the efficacy of coronary stenting began to appear (Moïse, 2003). In most European countries, angioplasty now accounts for at least 70% of all revascularisations (Figure 3.8.2). The EU average is close to 80%. For a large number of EU countries, the growth in angioplasty was higher between 2000 and 2005, compared to the 2005-10 period. Countries such as Romania, Spain and Sweden, which had low rates of angioplasty in 2000, have witnessed high annual growth rates since then. Whilst variation in the use of angioplasty persists, the degree of variation has diminished over the past decade, as many countries have caught up with the early adopters of this technology. Coronary angioplasty has expanded surgical treatment options to wider sections of the patient population, although a UK study found that approximately 30% of all angioplasty procedures are a direct substitute for bypass surgery (McGuire et al., 2010). Angioplasty is however not a perfect substitute since bypass surgery is still the preferred method

for treating patients with multiple-vessel obstructions, diabetes and other conditions (Taggart, 2009). Coronary angioplasty is an expensive intervention, but it is much less costly than a coronary bypass surgery because it is less invasive. The estimated price of an angioplasty on average across European countries was about EUR 5 900 in 2009 compared with EUR 15 300 for a coronary bypass. Hence, for patients who would otherwise have received bypass surgery, the introduction of angioplasty has not only improved outcomes but has also decreased costs. However, because of the expansion of surgical interventions, overall costs have risen. A number of reasons can explain cross-country variations in the rate of angioplasty, including: i) differences in the incidence and prevalence of ischemic heart diseases; ii) differences in the capacity to deliver and pay for these procedures; iii) differences in clinical treatment guidelines and practices; and iv) differences in coding and reporting practices.

Definition and comparability The data relate to inpatient procedures, excluding coronary angioplasties performed or recorded as day cases. In most countries, the data refer to the number of patients who have received an angioplasty during a hospital stay, except in Austria, Belgium, Germany and Slovenia where they are based on a count of all procedures (including possibly several procedures per patient), leading to an overestimation compared with other countries. In Ireland and the United Kingdom, the data only include activities in publicly-funded hospitals, resulting in an underestimation (it is estimated that over 10% of all hospital activity in Ireland is undertaken in private hospitals). Data for Portugal relate only to public hospitals on the mainland.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

3.8. CARDIAC PROCEDURES (CORONARY ANGIOPLASTY)

3.8.1. Coronary angioplasty per 100 000 population, 2010 and change between 2000 and 2010 2010 (or nearest year)

Change 2000-10 (or nearest year) Germany

624

4.2

Belgium

469

197

France

197

Luxembourg

193

Slovenia

191

EU21

n.a. 3.3 4.2 20.4 9.4

182

Estonia

180

Sweden

177

Greece

n.a. 13.4 n.a.

172

Hungary

170

Netherlands

8.0 6.8

Denmark

158 136

Spain

132

Finland

4.0 12.4 7.1

Italy

131

4.5

Portugal

118

11.2

United Kingdom

Ireland

Poland

n.a. 6.9 8.9

Romania

29.2

Norway

238

8.2

Iceland

198

2.3

Switzerland

164

400

8.6

Czech Republic

205

800 600 Per 100 000 population

7.6

Austria

240

200

9.8

20 30 Average annual growth rate (%)

Note: Some of the variations across countries are due to different classification systems and recording practices. Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932704532

3.8.2. Coronary angioplasty as a share of total revascularisation procedures, 2000 and 2010 (or nearest year) 2000

2010

% of total revascularisation procedures 100 89

71 68

66 61

55 47 42

d an el Ic

ay rw

er it z Sw

nd la

nd la Po

k ar nm De

an nl Fi

nd la

r tu

er th Ne

l ga

13 EU

m lg

g bo m xe

nd la Ir e

It a

en ed

ria st Au

ce an Fr

Note: Revascularisation procedures include coronary bypass and angioplasty. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704551

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

3.9. CATARACT SURGERIES

In the past two decades, the number of surgical procedures carried out on a same-day basis, without any need for hospitalisation, has grown in European countries. Advances in medical technologies, particularly the diffusion of less invasive surgical interventions, and better anaesthetics have made this development possible. These innovations have also improved patient safety and health outcomes for patients, and have in many cases reduced the unit cost per intervention by shortening the length of stay in hospitals. However, the impact of the rise in same-day surgeries on health spending depends not only on changes in their unit cost, but also on the growth in the volume of procedures performed. There is also a need to take into account any additional cost related to post-acute care and community health services following the intervention. Cataract surgery provides a good example of a high volume surgery which is now carried out predominantly on a same-day basis in most European countries. The operation began to change from an inpatient to a same-day surgery in the 1980s in some countries such as Sweden (Henning et al., 1985), with the movement then spreading to other European countries at different speed. From a medical point of view, a cataract surgery using modern techniques should not normally require an hospitalisation. However, in some specific cases (e.g. general anesthesia or severe comorbidities), a hospital stay may be required (Lundström et al., 2012). Day surgery now accounts for over 90% of all cataract surgeries in many countries (Figure 3.9.1). However, the use of day surgery is still relatively low in some countries, such as Lithuania, Poland and the Slovak Republic. This may be explained by more advantageous reimbursement for inpatient stays, national regulations, obstacles to changing individual practices of surgeons and anaesthetists, and tradition (Castoro et al., 2007). These low rates may also reflect limitations in data coverage of outpatient activities in hospitals or outside hospitals. The number of cataract surgeries performed on a sameday basis has grown very rapidly in some countries over the past ten years, such as in Austria and Portugal (Figure 3.9.2), catching up to the high rates already observed in 2000 in Nordic countries, the Netherlands and Spain. In Portugal, the strong rise in the number of cataract surgeries performed as day cases rather than as inpatients has led to a sharp increase in the share of same-day surgery, rising from less than 10% in 2000 to over 90% in 2010 (Figure 3.9.1). In France, this share also increased from 32% in 2000 to 80% in 2010. In Luxembourg, the number of cataract surgeries carried out as day cases and outpatient cases (in or outside hospitals) has also risen rapidly, although they still account for only about half of all cataract surgeries.

Cataract surgery has now become the most frequent surgical procedure in many European countries. The operation is performed more often in women than men (around 60% vs. 40%), because it is related to age and women live longer (Lundström et al., 2012). While population ageing is one of the factors behind the rise in cataract surgery, the proven success, safety and cost-effectiveness of the operation as a day procedure has been a more important factor (Fedorowicz et al., 2004). In Sweden, there is evidence that cataract surgeries are now being performed on patients suffering from less severe vision problems compared to ten years ago. This raises the issue of how the needs of these patients should be prioritised relative to other patient groups (Swedish Association of Local Authorities and Regions and National Board of Health and Welfare, 2010). The European Registry of Quality Outcomes for Cataract and Refractive Surgery recently developed evidence-based guidelines to improve treatment and standards of care for cataract surgery (Lundström et al., 2012).

Definition and comparability Cataract surgeries consist of removing the lens of the eye because of the presence of cataracts which are partially or completely clouding the lens, and replacing it with an artificial lens. The surgery may involve in certain cases an overnight stay in hospital (inpatient cases), but in many countries it is now performed mainly as day cases (defined as a patient admitted to the hospital and discharged the same day) or outpatient cases in hospitals or outside hospitals (without any formal admission and discharge). However, the data for many countries do not include such outpatient cases in hospitals or outside hospitals, with the exception of the Czech Republic, France, Hungary and Luxembourg where they are included. Caution is therefore required in making cross-country comparisons of available data, given the incomplete coverage of same-day surgeries in several countries. In Denmark, Ireland, the Netherlands and the United Kingdom, the data only include cataract surgeries carried out in public hospitals, excluding any procedures performed in private hospitals and in the ambulatory sector (in Ireland, it is estimated that over 10% of all hospital activity is undertaken in private hospitals). The data for Spain only partially include activities in private hospitals.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

3.9. CATARACT SURGERIES

3.9.1. Share of cataract surgeries carried out as day cases, 2000 and 2010 (or nearest year) 2000

79.6

79.0 93.6

87.3 96.8 71.6

80.1

85.4

71.2

89.1

90.4

2010

91.9

93.4

85.9 95.9

92.8 97.4

98.1

83.1 98.2

82.8 98.7

82.0 99.0

99.6

% 100

48.9

7.9 1.0

n.a.

3.8

1.2

0.1

n.a.

9.3

16.8

17.4

28.4

32.8

38.6

42.9 31.6

37.6

32.0

52.7

it z

nd ov

ria st

ar ng

m xe

g1 ur

an Fr

ce 1

ly It a

la Ir e

i te

ic 1

r tu Po

n ai

en ed Sw

s nm

nd la er

1. Data for the Czech Republic, France, Luxembourg and Hungary include outpatient cases in hospitals and outside hospitals. Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932704570

3.9.2. Growth in cataract surgeries per capita, day cases and inpatient cases, 2000 to 2010 (or nearest year) Day cases

Inpatient cases

54.1

45.9

Average annual growth rate (%) 60

4.9

4.3

0.4

7.2

7.3

7.4

8.5

9.1

5.4

1.1

5.2

9.3

10.8

13.6

11.5

33.4

0.0

-2.6

-15.3

-22.0

-14.8

-5.2

-23.0

-26.7

-20.6

-15.7

-13.2

-17.9

-20

-12.2

-8.6

-8.5

-2.1

ay rw

la er it z Sw

d an el Ic

ly It a

d an nl Fi

en ed Sw

g m xe

ur bo

la er Lu

th Ne

s nd

n Sp

iu lg Be

la Ir e

a ni to Es

ce an Fr

nd la Po

ria st Au

r tu

-40

Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932704589

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

3.10. HIP AND KNEE REPLACEMENT

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

the knee replacement rate more than tripled. Similarly, in Spain, the hip replacement rate increased by 25% and the knee replacement rate more than doubled during the past decade. The growth rate for both interventions was somewhat slower in France, but still the hip replacement rate increased by nearly 10% while the knee replacement rate rose by 60% between 2000 and 2010.

Ostheoarthritis is one of the ten most disabling diseases in developed countries. Worldwide estimates are that 9.6% of men and 18.0% of women aged over 60 years have symptomatic osteoarthritis, including moderate and severe forms (WHO, 2010a). Age is the strongest predictor of the development and progression of osteoarthritis. It is more common in women, increasing after the age of 50 especially in the hand and knee. Other risk factors include obesity, physical inactivity, smoking, excess alcohol and injuries (EC, 2008b). While joint replacement surgery is mainly carried out among people aged 60 and over, it can also be performed among people at younger ages.

The growing volume of hip and knee replacement is contributing to health expenditure growth since these are expensive interventions. In 2009, the estimated price of a hip replacement on average across European countries was about EUR 7 300, while the price of a knee replacement was EUR 6 800.

Austria, Belgium, Germany and Switzerland have the highest rates of hip replacement (Figure 3.10.1). These countries also have the highest rates of knee replacement, along with Finland (Figure 3.10.2). Differences in population structure may explain part of these variations across countries, and age-standardisation reduces to some extent the variations across countries. But still, large differences remain and the country ranking does not change significantly after age standardisation (McPherson et al., 2012). Beyond different population structures, a number of other reasons may explain cross-country variations in the rate of hip and knee replacement: i) differences in the prevalence of osteoarthritis problems; ii) differences in the capacity to deliver and pay for these expensive procedures; and iii) differences in clinical treatment guidelines and practices. The rate of hip and knee replacement has increased over the past ten years in many European countries, due in part to population ageing but also the growing use of these interventions to improve functioning among elderly people (Figures 3.10.3 and 3.10.4). In Denmark, the hip replacement rate increased by 40% between 2000 and 2010, while

Definition and comparability Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant. It is generally conducted to relieve arthritis pain or treat severe physical joint damage following hip fracture. Knee replacement is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve the pain and disability of osteoarthritis. It may be performed for other knee diseases such as rheumatoid arthritis. Classification systems and registration practices vary across countries which may affect the comparability of the data. Some countries only include total hip replacement (e.g. Estonia) while most also include partial replacement. Certain countries only include initial knee replacement while others also include revisions. In Ireland, the data only include activities in publicly-funded hospitals (it is estimated that over 10% of all hospital activity is undertaken in private hospitals).

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

3.10. HIP AND KNEE REPLACEMENT

3.10.1. Hip replacement surgery, per 100 000 population, 2010 (or nearest year)

3.10.2. Knee replacement surgery, per 100 000 population, 2010 (or nearest year)

Germany

295

Austria

249

Belgium

245

Denmark France

225

Sweden

210 208

Finland

Denmark

163

Slovenia

Sweden

125

France

124 112

EU21

109

153

Italy

128

Czech Republic

159

EU24

142

Netherlands

170

Czech Republic

175 155

United Kingdom

181

Greece

178

Luxembourg

199

United Kingdom

187

Belgium

213

Luxembourg

201

Finland

225

Netherlands

213

Austria

Spain

104

147

Ireland

Italy

122

Hungary

Slovenia

Spain Latvia

Cyprus

Portugal

Hungary

Estonia

Poland

53 45 44

Latvia

Poland

Cyprus

Ireland

Romania

Portugal

Slovak Republic

Romania

Switzerland

266

Norway

242

Iceland 100

132

Norway

173

212

Iceland

200 300 Per 100 000 population

100

200 300 Per 100 000 population

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932704608

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932704627

3.10.3. Trend in hip replacement surgery, 2000-10, selected countries

3.10.4. Trend in knee replacement surgery, 2000-10, selected countries

Denmark

France

Germany

Austria

Denmark

France

Poland

Spain

EU24

Germany

Ireland

EU21

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

10 20

09 20

08 20

07 20

06 20

05 20

04 20

03 20

02 20

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932704646

100

150

200

250

Per 100 000 population 300

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932704665

3.11. PHARMACEUTICAL CONSUMPTION

The consumption of pharmaceuticals has increased over the past decade not only in terms of expenditure (see Indicator 5.5 “Pharmaceutical expenditure”), but also in terms of the volume or quantity of medicines consumed. This section reviews trends in the volume of consumption of three categories of pharmaceuticals: antibiotics, antidiabetics and antidepressants. Consumption of these medicines is measured through the defined daily dose (DDD) unit, as recommended by the WHO Collaborating Center for Drug Statistics (see the box on “Definition and comparability”). Antibiotics should not be used needlessly, as there is a clear correlation between their use and the emergence of resistant bacterial strains (Bronzwaer et al., 2002; Goossens et al., 2005). As with any other prescribed medicines, overprescribing exposes patients unnecessarily to risks of side-effects without achieving more rapid recovery (Fahey et al., 2004). The use of antibiotics varies across European countries, ranging from 10 DDDs per 1 000 people per day in Latvia, the Netherlands and Romania, to over 30 in Greece and Cyprus (Figure 3.11.1). Consumption has stabilised in several countries over the past decade, and it has decreased in some countries including Estonia, France, Hungary, Portugal and Slovenia. But antibiotic use has risen in other countries such as Belgium, Greece and Italy which already had higher-thanaverage consumption in 2000, thereby widening the gap with other European countries. One way of reducing unnecessary use is to avoid prescribing them for mild and/or viral infections. Many countries have launched information campaigns targeting physicians and patients to reduce consumption. At the international level, WHO launched in 2011 a campaign to stimulate co-ordinated efforts to promote appropriate and rational use of antibiotics (WHO, 2012b). Clinical guidelines in different European countries recommend the use of various medicines to treat people with diabetes to reduce the risk of cardiovascular and microvascular complications (Beckman et al., 2002; UKPDS, 1998). There is wide variation in the use of medicines for the treatment of diabetes across European countries, with consumption in Iceland and Estonia almost half that in Finland or Germany (Figure 3.11.2). This can be partly explained by the prevalence of diabetes, which is low in Iceland (see Indicator 1.10). However, some of the countries with the highest consumption do not have high diabetes prevalence (e.g. Finland, Germany and the United Kingdom). Between 2000 and 2010, the consumption of antidiabetics increased by 75% on average across EU member states. The growth rate was particularly strong in Finland, Germany and the Slovak Republic. The main reasons for this strong rise are increases in the proportion of people treated and the average dosages used in treatments (Melander et al., 2006).

Guidelines for the pharmaceutical treatment of depression vary across countries, and there is also great variation in prescribing behaviors among general practitioners and psychiatrists not only across countries, but also among individual practitioners in each country. Iceland has the highest level of consumption of antidepressants, followed by Denmark and Portugal (Figure 3.11.3). Part of the explanation for the high consumption in Iceland is that a much higher proportion of the population receives at least one prescription for an antidepressant each year. In 2008, almost 30% of women aged 65 and over had an antidepressant prescription in Iceland, compared with less than 15% in Norway (NOMESCO, 2010). But the intensity and duration of treatments also play a role in explaining variations across countries and trends over time. In all European countries for which data is available, the consumption of antidepressants has increased a lot over the past decade, by over 80% on average across EU member states. While some analysts interpret these findings as evidence of a growing prevalence of depression, this also reflects greater efforts to provide treatments to people suffering from severe depression and greater intensity of these treatments. This rise can also be explained by the extension of the set of indications of some antidepressants to milder forms of depression, generalised anxiety disorders or social phobia, which have raised issues in some countries about the appropriateness of such extensions of prescriptions.

Definition and comparability Defined daily dose (DDD) is the assumed average maintenance dose per day for a medicine used for its main indication in adults. DDDs are assigned to each active ingredient(s) in a given therapeutic class by international expert consensus. For instance, the DDD for oral aspirin equals 3 grams, which is the assumed maintenance daily dose to treat pain in adults. DDDs do not necessarily reflect the average daily dose actually used in a given country. DDDs can be aggregated within and across therapeutic classes of the Anatomic-Therapeutic Classification (ATC). For more detail, see www.whocc.no/atcddd. Data generally refer to outpatient consumption except for the Czech Republic, Finland and Sweden, where data also include hospital consumption. Greek figures may include parallel exports.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

3.11. PHARMACEUTICAL CONSUMPTION

3.11.1. Antibiotics consumption, 2000 and 2010 (or nearest year) 2000

2010

Defined daily dose, per 1 000 people per day 45 40

39 34

35 30 25 20 15

tia

ay Cr

It a

iu lg

ak ov

ec Cz

i te Un

r tu

Ir e

ai Sp

ar h

lg Bu

an nl

ria

ar ng

ia Ge

a ni

er th

Source: OECD Health Data 2012; European Surveillance of Antimicrobial Consumption (ESAC) project, 2011.

1 2 http://dx.doi.org/10.1787/888932704684

3.11.2. Antidiabetics consumption, 2000 and 2010 (or nearest year) 2000 Estonia

2010 Estonia

Spain Belgium Slovak Republic Luxembourg

Portugal France

Netherlands

Czech Republic Slovenia

Luxembourg

Germany 62

France

EU18

United Kingdom

Finland

Iceland

50 75 100 Defined daily dose, per 1 000 people per day

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704703 HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

61 66

Belgium

Finland

69 76

Portugal

Denmark

Norway

Sweden

Germany

United Kingdom 71

Czech Republic

Spain

Hungary

Netherlands

Italy

EU15

Slovak Republic

2010

Hungary

Sweden

Slovenia

2000

Denmark

Italy

3.11.3. Antidepressants consumption, 2000 and 2010 (or nearest year)

Iceland

101

60 90 120 Defined daily dose, per 1 000 people per day

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704722

3.12. UNMET HEALTH CARE NEEDS

All European countries endorse equity of access to health care for all people as an important policy objective. One method of gauging to what extent this objective is achieved is through assessing reports of unmet needs for health care. The problems that people report in obtaining care when they are ill or injured often reflect significant barriers to care. Some common reasons given for not receiving care include excessive treatment costs, long waiting times, not being able to take time off work or needing to look after children, or having to travel too far to receive care. Differences in the reporting of unmet care needs across countries may be due partly to socio-cultural differences. However, these factors play a lesser role in explaining any differences among population groups within each country. It is also important to consider self-reported unmet care needs in conjunction with other indicators of potential barriers to access, such as the extent of health insurance coverage and the amount of out-of-pocket payments (see Indicators 5.1 “Coverage for health care” and 5.6 “Financing of health care”). In all European countries, a majority of the population reported no unmet care needs, according to the 2010 EU Statistics on Income and Living Conditions survey (EU-SILC). However, in some countries, significant proportions of people reported having unmet needs. In Bulgaria, Croatia, Latvia, Poland, Romania and Sweden, more than 10% of survey respondents had an unmet need for a medical examination, and the burden fell heaviest on low income earners, particularly in Bulgaria and Latvia (Figure 3.12.1). On average across EU member states, twice as many low income earners reported unmet needs as did high income earners, indicating that affordability remains an important issue for some population groups. The most common reason for not obtaining care was because of treatment costs, and this was particularly the case in Latvia and Romania. Waiting times were an issue for some people in Bulgaria, Estonia, Finland and Poland. Generally, women tend to report slightly more unmet health care needs than men. Aside from people in lowincome groups, those who are unemployed or less

educated are also more likely to report unmet needs (Figure 3.12.3). A larger proportion of the population indicates unmet needs for dental care than for medical care. Often, dental care is only partially included, or not included at all in basic health care coverage, and so must either be paid out-of-pocket, or covered through purchasing private health insurance. Latvia (21.5%) reported the highest rates of unmet need for a dental examination in 2010, followed by Bulgaria, Portugal, Romania, Cyprus, Iceland, Italy and Poland (all between 10-15%) (Figure 3.12.2). Large inequalities in unmet dental care needs were evident between high and low income groups in most of these countries. The population in Belgium, the Netherlands, Slovenia and the United Kingdom reported the lowest rates of unmet dental care needs in 2010 (between 1% and 3% only), according to EU-SILC.

Definition and comparability Questions on unmet health care needs are a feature of a number of national and cross-national health interview surveys, including the European Union Statistics on Income and Living Conditions survey (EU-SILC). To determine unmet medical and dental care, individuals are asked in EU-SILC whether there was a time in the previous 12 months when they felt they needed health care or dental care services but did not receive them, followed by a question as to why the need for care was unmet. Common reasons given include that care was too expensive, the waiting time was too long, or wanting to wait to see if the problem would get better. Cultural factors and policy debates may affect responses to questions about unmet care. Caution is therefore needed in comparing the magnitude of inequalities across countries.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

3.12. UNMET HEALTH CARE NEEDS

3.12.1. Unmet need for a medical examination, by income quintile, 2010 High income

Average

3.12.2. Unmet need for a dental examination, by income quintile, 2010

Low income

High income

Latvia Bulgaria Poland Romania Sweden Hungary Greece Italy Spain Cyprus EU27 Germany Estonia Malta Finland Slovak Republic France Denmark United Kingdom Czech Republic Luxembourg Lithuania Ireland Portugal Austria Netherlands Belgium Slovenia

Latvia Bulgaria Portugal Romania Cyprus Italy Poland Spain Sweden France Greece EU27 Estonia Finland Hungary Austria Ireland Czech Republic Slovak Republic Malta Germany Denmark Lithuania Luxembourg United Kingdom Belgium Netherlands Slovenia

Croatia Iceland Norway Switzerland

Iceland Croatia Norway Switzerland 0

40 %

Source: Eurostat Statistics Database, based on EU-SILC. 1 2 http://dx.doi.org/10.1787/888932704741

Average

Low income

40 %

Source: Eurostat Statistics Database, based on EU-SILC. 1 2 http://dx.doi.org/10.1787/888932704760

3.12.3. Inequalities in unmet need for a medical examination, EU27 average, 2010 % 12 Gender

Age group

Income

Education level

Activity status 9.3

9.2 8.0

7.4

7.3

7.0

6.7

7.5

7.2

6.9

7.0

6.3

6.0

5.9

5.5

5.7

5.4 4.8 4.3

3.5

oy pl em

pl Em

t ir

dl id

t es M

gh Hi

t il

(lo

t il

e3 in

t il in Qu

h) ig

t il in Qu

(h Qu

t il

+ 85

-7 4

-8 75

-6

4 55

-5 45

-4

4 35

-3 25

18 -

es al m

Source: Eurostat Statistics Database, based on EU-SILC.

1 2 http://dx.doi.org/10.1787/888932704779

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

Health at a Glance: Europe 2012 ÂŠ OECD 2012

Chapter 4

Quality of care

Care for chronic conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.1.

Avoidable admissions: Respiratory diseases. . . . . . . . . . . . . . . . . . . . .

4.2.

Avoidable admissions: Uncontrolled diabetes . . . . . . . . . . . . . . . . . . .

Acute care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.3.

In-hospital mortality following acute myocardial infarction . . . . . . .

4.4.

In-hospital mortality following stroke . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 4.5.

Procedural or postoperative complications. . . . . . . . . . . . . . . . . . . . . . 102

4.6.

Obstetric trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Cancer care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 4.7.

Screening, survival and mortality for cervical cancer . . . . . . . . . . . . . 106

4.8.

Screening, survival and mortality for breast cancer . . . . . . . . . . . . . . 108

4.9.

Screening, survival and mortality for colorectal cancer . . . . . . . . . . . 110

Care for communicable diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 4.10. Childhood vaccination programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 4.11. Influenza vaccination for older people . . . . . . . . . . . . . . . . . . . . . . . . . 114

CARE FOR CHRONIC CONDITIONS

• 4.1. AVOIDABLE ADMISSIONS: RESPIRATORY DISEASES

Both asthma and chronic obstructive pulmonary disease (COPD) are, to a considerable degree, either preventable or manageable through proper prevention or primary care interventions. Proper management of these chronic conditions in primary care settings can reduce exacerbation and costly hospitalisation (Menn et al., 2012). Hospital admission rates serve as a proxy for primary care quality, whereby high admission rates may point to poor care co-ordination or care continuity. They may also indicate structural constraints such as an inadequate supply of family physicians (Rosano et al., 2012). Asthma is a condition that affects the airways that carry air in and out of the lungs. Asthma symptoms are usually intermittent and treatment can be highly effective, even often reversing the effects of bronchial irritation. A recent survey conducted in 70 countries showed that the global prevalence of clinically treated asthma in adults was estimated to be 4.5%. However, asthma prevalence in some European countries was amongst the highest in the world, with the Netherlands, Sweden and the United Kingdom having prevalence rates of 15% or higher (To et al., 2012). COPD, on the other hand, is a progressive disease. It affects around 64 million worldwide and tobacco use is a major risk factor (WHO, 2011a). In 2008, COPD accounted for around 3% of total deaths in the European Union (WHO, 2011b). A Danish study found that COPD patients use over three times as many hospital bed-days and twice as many general practice visits as similar aged patients without COPD; overall, COPD accounted for 6% of the total annual health care costs of treating the population aged 40 and over (Bilde et al., 2007). Figure 4.1.1 shows that among the EU member states, asthma accounts for an average of 53 hospital admissions per 100 000 population in 2009. Asthma-related admissions in the Slovak Republic and Latvia were more than double the EU average, whereas Portugal, Italy, Sweden and Germany report rates that are less than half the EU average. Adult females experienced higher rates for asthma admissions compared to males in all countries. On average, the female admission rate was around 70% higher than the male hospitalisation rate. This is in contrast to the results found amongst children where both asthma prevalence and

hospital admissions are highest amongst boys (Lin and Lee, 2008). The reasons for gender differences in asthmarelated hospital admissions are not well understood (Melero-Moreno et al., 2012). The incidence of asthma among women has increased and “asthmatic women have poorer quality of life and increased utilisation of health care compared to males, despite having similar medical treatment and baseline pulmonary function” (Kynyk et al., 2011). As shown in Figure 4.1.2, the average COPD-related admission rate was 184 per 100 000 population in EU member states in 2009, nearly four times greater than for asthma. By contrast to asthma-related admissions, males had a higher COPD admission rates than females in most countries. Notable exceptions were Denmark, Iceland, Norway and Sweden where there were no statistically significant differences between males and females. Ireland and Austria have the highest admission rates for COPD. Portugal, France and Switzerland have rates that are less than half the EU average. Whilst some of the variation undoubtedly reflects differences in smoking rates, there is evidence that differences in the quality of care may also play an important role. Based on preliminary results of a 13 European countrywide evaluation, both process of care and outcomes vary considerably between and within countries. The evaluation showed that approximately 50% of COPD admissions lead to a re-admission or death within 90 days (Hartl et al., 2011).

Definitions and comparability The asthma and COPD indicators are defined as the number of hospital discharges of people aged 15 years and over per 100 000 population, adjusted to take account of the age and sex composition of each country’s population structure. Differences in diagnosis and coding between asthma and COPD across countries may limit the precision of the specific disease rates. Differences in disease classification systems, for example between ICD-9-CM and ICD-10-AM, may also affect the comparability of the data.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

CARE FOR CHRONIC CONDITIONS

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4.1. AVOIDABLE ADMISSIONS: RESPIRATORY DISEASES

4.1.1. Asthma hospital admission rates, population aged 15 and over, 2009 (or nearest year) Male Portugal Italy Sweden Germany Netherlands Hungary Denmark Czech Republic Slovenia France Ireland Spain Belgium Austria EU20 Poland United Kingdom Finland Malta Latvia Slovak Republic

15 19 19 21 27 35 36 37 38 43 44 44 48 53 53 69 74 76 79 121 167

200 150 Rates per 100 000 population

100

26 33

43 54

100

102

113

130 216

116

Switzerland Iceland Norway

31 33

Female

120

180 240 Rates per 100 000 population

Note: Rates are age-sex standardised to the 2005 OECD standard population. 95% confidence intervals represented by H. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704798

4.1.2. COPD hospital admission rates, population aged 15 and over, 2009 (or nearest year) Male Portugal France Slovenia Italy Malta Sweden Spain Finland Czech Republic Netherlands Latvia EU20 Germany Slovak Republic United Kingdom Poland Belgium Hungary Denmark Austria Ireland

71 79 114 126 135 137 139 146 149 154 163 184 201 206 213 217 228 248 277 310 364

243

200

100

Female

107

123 65

185 84

187

261 143 137

276 84

241 105

209 136

189

248 138

251 159

259

135

303 203

233

136

330 173

308 202

310 238

284 275 397 324

Switzerland Iceland Norway

91 229

400 300 Rates per 100 000 population

123

207

100

437

200

241 226 266

300

400 500 Rates per 100 000 population

Note: Rates are age-sex standardised to the 2005 OECD standard population. 95% confidence intervals represented by H. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704817

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

CARE FOR CHRONIC CONDITIONS

• 4.2. AVOIDABLE ADMISSIONS: UNCONTROLLED DIABETES

The health and economic burden of diabetes continues to rise. Across the European Union there are an estimated 31 million adults living with diabetes and many people remain undiagnosed (Mladovsky et al., 2009). Diabetes leads to an increased risk of cardiovascular disease, blindness, kidney disease, lower limb amputation and mortality. Across Europe, the treatment and management of diabetes has been estimated to account for approximately 10% of total health care expenditure (Zhang et al., 2010). There is a considerable body of evidence on how best to prevent and treat diabetes. Modest weight loss and dietary changes can delay or even prevent the onset of diabetes by almost 60% (DPP, 2002). Better management of blood glucose levels in Type 2 diabetes patients can reduce microvascular complications by 25% (UKPDS, 1998) and non-fatal myocardial infarctions by 17% (Ray et al., 2009). However, health care systems have historically struggled with optimising diabetes care and many patients do not seek treatment until complications have set in. Figure 4.2.1 shows the extent to which the failure of effectively controlling and managing diabetes manifests in avoidable hospital admissions. The figure shows that the EU average for uncontrolled diabetes admissions (without complications) is 50 per 100 000 population. For admissions with short- and long-term diabetes complications, the EU average is 109 per 100 000 population. Males tend to have higher admission rates than females even though evidence suggests that there are no significant gender differences in diabetes prevalence (DECODE Study Group, 2003). Figure 4.2.2 examines the relationship between diabetes prevalence and avoidable admissions. The line in the graph indicates that countries with higher disease prevalence tend to have higher rates of diabetes-related admissions. However, substantial variations remain even after controlling for disease prevalence, with countries such as Austria, the Czech Republic and Poland having higher rates of admissions, whereas Spain, Switzerland and Portugal experience lower rates. The variation in diabetes-related hospital admissions (after taking prevalence into account) suggests that other factors, such as adherence to highquality diabetes care, may also play a role. In combating the challenges posed by diabetes, a number of countries have introduced initiatives to reduce the impact of the disease. For example, a number of European countries have recently introduced taxes on unhealthy food and drink to promote better nutrition and reduce obesity, an important risk factor for diabetes (OECD, 2012b). Austria has introduced a disease management programme, with early indications showing some success in process quality and enhanced weight loss, but no significant improvement in diabetes control (Sönnichsen et al., 2010). As part of the United Kingdom’s Quality and Outcomes Framework, up to 25% of British practice income is linked to performance, including a range of diabetes indicators such as glucose control, medication compliance and foot care

(Adler, 2012). In France, results from a two year pay-forperformance pilot has shown positive results in diabetes management through better medication compliance and glucose control (Polton, 2012). Alongside national initiatives, there are also some recent examples of international diabetes collaborations. In April 2012, the European Diabetes Leadership Forum brought together a wide range of stakeholders to produce the Copenhagen Roadmap outlining initiatives to improve diabetes prevention, early detection and intervention as well as management and control (see www.diabetesleadershipforum.eu for more information). In the European Union, the EUBIROD Project has developed a European Diabetes Register that brings together data from across Europe. The registry allows comparisons across Europe on how diabetes is treated and share knowledge to reduce the burden of diabetes (EC, 2012b).

Definitions and comparability The indicator for uncontrolled diabetes hospital admission rates with and without complications is based on the sum of the three indicators: i) shortterm diabetes complications; ii) long-term diabetes complications; and iii) uncontrolled diabetes without complications. The indicator for admissions with short-term diabetes complications is defined as all non-maternal/ non-neonatal hospital admissions of people aged 15 years and over with a principal diagnosis code for diabetes short-term complications including coma and ketoacidosis, caused by a shortage of insulin in the body. The indicator for long-term diabetes complications is defined similarly but where the principal diagnosis code indicates the presence of long-term diabetes complications such as renal, eye or circulatory complications. The indicator for uncontrolled diabetes without complications is defined as all non-maternal/non-neonatal hospital admissions of people aged 15 years and over with a principal diagnosis code for uncontrolled diabetes, without mention of a short-term or long-term complication. The rates are per 100 000 population and have been adjusted to take account of the age and sex composition of each country’s population structure. Differences in coding practices among countries may affect the comparability of data. Differences in disease classification systems, for example between ICD-9-CM and ICD-10-AM, may also affect the comparability of the data.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

CARE FOR CHRONIC CONDITIONS

â&#x20AC;˘

4.2. AVOIDABLE ADMISSIONS: UNCONTROLLED DIABETES

4.2.1. Uncontrolled diabetes hospital admission rates with and without complications, population aged 15 and over, 2009 (or nearest year) With complications

Without complications

Male 3

169 170 253 218 262 211

Czech Republic

293 298

Austria

188

34 46

411

Iceland

Switzerland

71 50 81 86

Norway

200

149

Poland

220

186

Germany

159

191 135

Malta

119

400 300 Rates per 100 000 population

192 126

EU15

109

167

180 114

Finland

175

119

Ireland

162 140 153

Denmark

65 115

141 103

Latvia

130 82

108 97

Sweden

108 86

Slovenia

85 76

Portugal

81 64

Italy

Spain United Kingdom

Female

100

110

100

200

300

400 500 Rates per 100 000 population

Note: Rates are age-sex standardised to the 2005 OECD standard population. Male and female rates refer to the sum of admissions with and without diabetes complications. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704836

4.2.2. Uncontrolled diabetes hospital admission rates and prevalence of diabetes, 2009 (or nearest year) Admissions per 100 000 population 400 R 2 = 0.18 AUT

350 300 250

CZE

POL DEU

200 DNK

150

IRL

MLT FIN

LVA

NOR

SVN SWE

100 GBR

ESP

ISL

PRT

ITA CHE

0 0

9 10 Prevalence of diabetes (%)

Note: Prevalence estimates of diabetes refer to adults aged 20-79 years and data are age-standardised to the World Standard Population. Hospital admission rates refer to the population aged 15 and over and are age-sex standardised to the 2005 OECD standard population. Source: IDF (2009) for prevalence estimates; OECD Health Data 2012 for hospital admission rates.

1 2 http://dx.doi.org/10.1787/888932704855

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

ACUTE CARE •

4.3. IN-HOSPITAL MORTALITY FOLLOWING ACUTE MYOCARDIAL INFARCTION

Care for AMI (heart attack) has changed dramatically in recent decades (Khush et al., 2005; Gil et al., 1999). Clinical practice guidelines, such as those developed by the European Society of Cardiology, provide clinicians with the best available evidence on how to optimise care. Numerous studies have shown that greater compliance with guidelines improves health outcomes (e.g. Schiele et al., 2005; Eagle et al., 2005). However, a considerable proportion of AMI patients do not receive recommended care (Brekke and Gjelsvik, 2009; Kotseva et al., 2009). AMI case-fatality rates refer to the percentage of patients who die within 30 days after a hospital admission for AMI. This rate is a good measure of acute care quality because there is a clear link between the processes of care and health outcomes (Bradley et al., 2006). AMI case-fatality rates have been used for hospital benchmarking in several countries including Denmark and the United Kingdom, and have been used in the academic literature as a wider marker for hospital quality (e.g. Kessler and Geppert, 2005; Cooper et al., 2011). However, the indicator is influenced by not only the quality of care provided in hospitals but also differences in hospital transfers, average length of stay, emergency retrieval times and average severity of AMI.

countries. Figure 4.3.2 presents AMI case-fatality rates for the nine countries for which both admission-based and patient-based data are available. It confirms that patientbased indicators are higher than hospital-based rates, but the degree of cross-country variation is considerably less compared to the admission-based indicator. The average patient-based AMI case-fatality rate is 6.9% and ranges from 5.5% (Sweden) to 7.8% (Slovenia). Case-fatality rates for AMI have decreased over time, with almost all countries recording sizeable reductions between 2000 and 2009 (Figure 4.3.3). The AMI case-fatality rate for the ten EU member states reporting data over this period fell by nearly 50% between 2000 and 2009. These substantial improvements reflect better and more reliable processes of care, in particular with respect to rapid re-opening of the occluded arteries. Most of these improvements were made between 2000 and 2005, with fewer gains in more recent years.

Definitions and comparability

Figure 4.3.1 shows the crude and age-standardised AMI case-fatality rates, when the death occurs within a 30-day period and in the same hospital as the initial AMI admission. The average age-standardised AMI case-fatality rate across the European Union is 5% but rates vary widely between countries. The lowest age-standardised rates are found in Denmark and Norway (2.3% and 2.5%, respectively) and the highest rate is in Belgium (8.6%), although some of the variation between countries may be explained by differences in data definitions (see box on “Definitions and comparability”). The Minister of Health in Belgium introduced new reforms in 2012 that aim to minimise res ponse time for ca rdia c interventions, imp rove co-operation within provider networks, set new care standards, as well as new minimum activity thresholds in hospitals which are aimed at reducing AMI case-fatality rates (Onkelinx, 2012).

In-hospital case-fatality rate following AMI is defined as the number of people who die within 30 days of being admitted (including same day admissions) to hospital with an AMI. Ideally, rates would be based on individual patients; however, not all countries have the ability to track patients in and out of hospitals, across hospitals or even within the same hospital because they do not currently use a unique patient identifier. In order to increase country coverage, this indicator is also presented based on individual hospital admissions and restricted to mortality within the same hospital, so differences in practices in discharging and transferring patients may influence the findings. In counting the number of AMI admissions, Belgium excludes transfers to other hospitals from the denominator leading to some over-estimation.

Patient-based data, which follow patients in and out of hospitals and across hospitals, is a more robust indicator for international comparison than admission-based data, as admission-based data may bias case-fatality rates downwards if unstable cardiac patients are commonly transferred to tertiary care centres. Unfortunately, patientbased data is only available for a relatively small group of

Both crude and age-sex standardised rates are presented for admission-based data. Standardised rates adjust for differences in age (45+ years) and sex and facilitate more meaningful international comparisons. Crude rates are likely to be more meaningful for internal consideration by individual countries.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

ACUTE CARE

•

4.3. IN-HOSPITAL MORTALITY FOLLOWING ACUTE MYOCARDIAL INFARCTION

4.3.1. Admission-based in-hospital case-fatality rates within 30 days after admission for AMI, 2009 (or nearest year) Crude rates

Age-sex standardised rates

4.5

2.5

3.0

5.0

7.1

6.9

8.6

10.4 6.8

9.7 7.3 5.7

6.6

8.6 5.7

5.6

7.2 5.3

8.4

9.1

5.0

5.2

7.7 5.0

4.8

6.4 4.7

6.6 4.3

4.8 3.9

4.3

6.5 3.7

2.9

3.9 2.3

6.6

6.8

5.2

10.6

13.4

Rates per 100 patients 16

it z

rw No

m lg Be

rm Ge

r tu

Re ak

i te

er th

ria

s nd la

do ng

bo m xe

h Cz

g ur

ia en

ic bl

pu Re

Ir e

ly It a

Note: Rates are age-sex standardised to the 2005 OECD standard population (45+). 95% confidence intervals represented by H. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704874

4.3.2. Comparing admission-based and patient-based in-hospital case-fatality rates within 30 days after admission for AMI, selected EU countries, 2009 (or nearest year) Admission-based rates (same hospital)

Patient-based rates (in and out of hospital)

2.9

2.3

4.8

7.2

5.2

5.3

6.8

6.7 4.3

7.6

3.9

4.7

5.5

6.4

6.9

5.2

7.8

Rates per 100 patients 12

s nd la er th Ne

d i te Un

d nl Fi

ic bl

nd la Po

Note: Rates are age-sex standardised to the 2005 OECD standard population (45+). 95% confidence intervals represented by H. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704893

4.3.3. Reduction in in-hospital case-fatality rates within 30 days after admission for AMI, 2000-09 (or nearest year)

9.0 8.1 11.1

4.2

5.7

6.6

6.8

6.6

5.6

5.3

6.3 3.8

5.5

4.8

4.7

9.4

9.0

5.2

8.3

8.9 10.5

4.3

5.7

6.6

6.2

2.5

2.3

2.9

3.4

3.9

4.3

6.2

6.3

10 8

2009

7.6

9.9

2005

10.3

2000 Rates per 100 patients 12

ay No

l Po

r tu

ria st Au

n ai Sp

s la er th

m xe

d Lu

an nl Fi

pu Re h ec Cz

ic bl

nd la Ir e

en ed Sw

Note: Rates are age-sex standardised to the 2005 OECD standard population (45+). 95% confidence intervals represented by H. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704912 HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

ACUTE CARE •

4.4. IN-HOSPITAL MORTALITY FOLLOWING STROKE

In Europe, stroke and other cerebrovascular diseases account for around 9% of all deaths and are the third most common cause of death (OECD, 2012a, based on the WHO Mortality Database). Stroke is also a major cause of adult disability. Around one third of all stroke incidents lead to permanent sequelae and dependency (WHO, 2004b). In ischemic stroke, representing about 85% of cases, the blood supply to a part of the brain is interrupted, leading to a necrosis of the affected part, while in hemorrhagic stroke, the rupture of a blood vessel causes bleeding into the brain, usually causing more widespread damage. Treatment for ischemic stroke has advanced dramatically over the last decades. Since the 1990s, clinical trials have demonstrated clear benefits of thrombolytic treatment for ischemic stroke in both European (e.g. Hacke et al., 1995) and non-European countries (e.g. Mori et al., 1992; NINDS, 1995). Dedicated stroke units were introduced in many countries, to facilitate timely and aggressive diagnosis and therapy for ischemic and haemorrhagic stroke victims, achieving better survival than usual care (Seenan et al., 2007). Whilst there is only limited international data on stroke unit access, there are some indications that access varies across and within countries (OECD, 2003; Abilleira et al., 2012; Rudd et al., 2007). Stroke survival reflects quality of acute care, particularly effective treatment methods such as thrombolysis and prompt and adequate care delivery (Abilleira et al., 2012). Consequently, stroke case-fatality rates have been used for hospital benchmarking within and between OECD countries. While the standardised case-fatality rate for ischemic stroke was about 5.4% on average across EU member states in 2009, there were large differences between the highest rate in Slovenia (9.7%) and the lowest rate in Denmark (2.6%) (Figure 4.4.1). The average standardised rate for hemorrhagic stroke is 20.2% (Figure 4.4.2), about four times greater than the rate for ischemic stroke, reflecting the more severe effects of intracranial bleeding. There is a six-fold cross-country difference between the highest and lowest percentage of in-hospital case-fatality for hemorrhagic stroke. In Finland, 6.5% of hemorrhagic stroke admissions lead to a death within 30 days, whereas in Belgium the corresponding figure is 38.6%. One potential reason for this is that patients are not systematically transported to hospitals with dedicated stroke units in Belgium so that some patients miss out on optimal care. The variation between countries may also, in part, be explained by differences in data definitions (see box on “Definitions and comparability”). There is a high degree of correlation between the two case-fatality indicators for ischemic and hemorrhagic stroke, with countries that achieve better survival for one type of stroke tending to do well for the other type. This

100

suggests that system-based factors such as access to specialised stroke care, average length of stay, emergency retrieval times as well as stroke severity may also influence the case-fatality rates. Between 2000 and 2009, case-fatality rates for ischemic stroke declined by over 20% across EU member states (Figure 4.4.3). These reductions suggest overall improvements in the quality of care for stroke patients, with gains made in most countries for which data is available. However, improvements were not uniform across countries. Improvements in Ireland and Portugal were below the EU average, while the rate in Luxembourg did not change significantly over the period. On the other hand, Norway was able to reduce its fatality rate by 55% between 2000 and 2009. The improvements in case-fatality rates can at least be partially attributed to the high level of access to dedicated stroke units in countries such as Norway, Denmark and Sweden (Indredavik, 2009).

Definitions and comparability In-hospital case-fatality rate following ischemic and hemorrhagic stroke is defined as the number of people who die within 30 days of being admitted (including same day admissions) to hospital. Ideally, rates would be based on individual patients; however, not all countries have the ability to track patients in and out of hospitals, across hospitals or even within the same hospital because they do not currently use a unique patient identifier. Therefore, this indicator is based on unique hospital admissions and restricted to mortality within the same hospital, so differences in practices in discharging and transferring patients may influence the findings. In counting the number of stroke admissions, Belgium excludes transfers to other hospitals from the denominator leading to some over-estimation. The Czech Republic, Denmark, Finland, Luxembourg, the Netherlands, Poland, Slovenia, Sweden and the United Kingdom also provided patient-based (in and out of hospitals) data. Their relative performance is generally similar as the case-fatality rate within the same hospital, although the rates are obviously higher. Both crude and age and sex standardised rates are presented. Standardised rates adjust for differences in age (45+ years) and sex and facilitate more meaningful international comparisons. Crude rates are likely to be more meaningful for internal consideration by individual countries.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

ACUTE CARE

4.4.1. In-hospital case-fatality rates within 30 days after admission for ischemic stroke, 2009 (or nearest year) Crude rates Denmark

6.3 7.3

3.4

Sweden Germany Luxembourg

9.6

19.3

7.1 8.6

Slovenia

9.7

30.6 24.3 28.8 25.1

15.3

Slovak Republic

29.0 25.5

15.3

Belgium

38.6

Norway

19.7 14.1

Switzerland

15 20 Rates per 100 patients

45.8

16.6

11.6

Iceland

8.2

4.3

27.4

25.2 23.9

Slovenia

8.0

2.8

23.9

Luxembourg

6.5

2.8

27.3

25.4 23.0

Spain

12.9

24.1 22.4

Ireland

10.7

Belgium

20.2

Portugal

6.8

Slovak Republic

23.3

Netherlands

11.1

6.2

22.2

17.6

Czech Republic

10.2

6.1

United Kingdom

19.7 16.4

United Kingdom

11.0

6.1

Portugal

17.6 13.8

21.3 18.0

10.3

Ireland

17.2

EU16

5.8

Spain

12.8

8.6

5.7

Czech Republic

Switzerland

Sweden

Italy

5.4

Netherlands

Iceland

15.6 12.1

Denmark

8.3

4.5

EU16

Austria

8.0

4.0

6.5

Age-sex standardised rates

9.3

Germany 8.4

3.9

Norway

Crude rates Finland

3.1

Italy

Age-sex standardised rates

5.8

2.8

Austria

4.4. IN-HOSPITAL MORTALITY FOLLOWING STROKE

4.4.2. In-hospital case-fatality rates within 30 days after admission for hemorrhagic stroke, 2009 (or nearest year)

4.6

2.6

Finland

â&#x20AC;˘

14.8

19.9

40 50 Rates per 100 patients

Note: Rates are age-sex standardised to the 2005 OECD standard population (45+). 95% confidence intervals represented by H.

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704931

1 2 http://dx.doi.org/10.1787/888932704950

4.4.3. Reduction in in-hospital case-fatality rates within 30 days after admission for ischemic stroke, 2000-09 (or nearest year) 2005

2000

2009

8.1

6.1

6.2

6.1

7.1

7.0 6.9 6.1

5.8

5.7

3.5

4.7

5.5

6.0 3.0

3.9

4.2

3.8

5.2

4.1

2.8

3.1

3.9

3.7

3.9 3.2

2.6

3.4

3.5

6.6

4.5

7.2

7.9

9.0

9.7

Rates per 100 patients 12

ay No

l Po

r tu

nd la

Ir e

bl pu

la er th

s nd

10 Ne

bo m xe Lu

g ur

en ed

st Au

ria

d an nl Fi

Note: Rates are age-sex standardised to the 2005 OECD standard population (45+). 95% confidence intervals represented by H. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704969

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

101

PATIENT SAFETY • 4.5. PROCEDURAL OR POSTOPERATIVE COMPLICATIONS

Several European studies have documented that between 8% and 12% of patients admitted to hospitals suffer from adverse effects whilst receiving health care (UK Department of Health, 2000; WHO Europe, 2012b). The European Commission estimates that without any policy changes, there are likely to be 10 million adverse events related to hospitalisations (including infection-related ones) in the European Union per year, of which almost 4.4 million would be preventable (EC, 2008d). Patient safety has, in recent years, become an important part of the policy agenda in Europe. In 2009, the Council of the European Union adopted a recommendation on patient safety, including the prevention and control of health care associated infections (European Union, 2009). This recommendation is intended to bring about a political commitment from all EU member states to address the patient safety challenge. Figures 4.5.1 to 4.5.4 show reported complication rates related to surgical and medical care for four patient safety indicators: i) sentinel events, such as a foreign body left in a person during a surgical procedure, are those that in theory and practice should never happen and thus whose occurrence indicates failure of safeguards to protect patients during care delivery; ii) accidental puncture or laceration during a surgical procedure is a recognised risk, but increased rates of such complications may indicate system problems; iii) postoperative pulmonary embolism and deep vein thrombosis cause unnecessary pain and death, but can be prevented through the appropriate use of anticoagulants and other preventive measures; and iv) sepsis after elective surgery is a severe complication that can lead to multiple organ dysfunction and death. Many cases of postoperative sepsis can be prevented through infection prevention measures such as hand hygiene, sterile surgical techniques, good postoperative care and, where necessary, the appropriate use of prophylactic antibiotics. Comparable data are available for between eight and thirteen European countries, depending on the indicator. There are considerable differences across countries for these four patient safety indicators. Whereas Denmark and Germany report complication rates that are below the EU average for each of the four patient safety indicators, other countries show less consistent results. For example, Belgium, France, Ireland and Switzerland perform well on some indicators but report worse than EU average results for others. Differences in the prevalence of patient safety complications across countries may reflect – at least in part –

102

differences in the willingness of health workers to admit to medical errors as well as differences in the sensitivity of monitoring or surveillance systems across countries. Nevertheless, these indicators do show that numerous patients have been affected by patient safety events. International efforts to harmonise documentation and data systems, and the results of ongoing validation studies, will provide more information on the validity and reliability of patient safety measures based on administrative hospital data in the future.

Definitions and comparability Patient safety indicators are derived from the Quality Indicators developed by the US Agency for Healthcare Research and Quality (AHRQ). AHRQ’s patient safety indicators are a set of indicators that provide information on hospital complications and adverse events following surgeries, procedures, and childbirth. The indicators were developed after a comprehensive literature review, analysis of ICD-9-CM codes, clinician panel review, implementation of risk adjustment, and empirical analyses (AHRQ, 2006). All procedural or postoperative complications are defined as the number of discharges with ICD codes for complication in any secondary diagnosis field, divided by the total number of discharges (medical and surgical or surgical only) for patients aged 15 and older. Data are based on administrative hospital discharge data. The rates have been age/sex standardised, apart from postoperative sepsis rate (this is due to the use of modified exclusion criteria within the algorithm for the calculation of this indicator).The patient safety rates have also been adjusted by the average number of secondary diagnoses (SDx) (Drösler et al., 2011) in order to improve cross-country comparability. Despite this adjustment, the results for the two countries (Finland and Italy) that are reporting less than 1.5 diagnoses per record may be underestimated. Differences in coding practice, coding rules (e.g. definition of principal and secondary diagnoses), coding for billing purposes and the use of diagnosis type markers (e.g. “present at admission”) may also influence indicators.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

PATIENT SAFETY

4.5.1. Foreign body left in during procedure, 2009 (or nearest year) SDx-adj. standardised rate

Italy

2.6 2.0

Italy1

4.5 3.4

Denmark

3.4

France

1.5

4.1 4.2

EU11

114 100 117 65 119 98 155 155 163

EU11 4.8 5.5

France

5.4

170 144 174 170 205

United Kingdom

6.1

Spain

Sweden

5.6 5.1 5.7

United Kingdom

Finland1

Portugal

255

Portugal 9.7

Belgium

13.3

Switzerland 4

546

Belgium

7.8

122 75 13

Ireland

3.3

Germany

Spain

2.7

Age-sex standardised rate 160

Germany

2.4

Sweden

Finland

SDx-adj. standardised rate

Age-sex standardised rate

2.0

Ireland

4.5. PROCEDURAL OR POSTOPERATIVE COMPLICATIONS

4.5.2. Accidental puncture or laceration, 2009 (or nearest year)

1.3 1.8

Denmark

â&#x20AC;˘

13.8

432

356 392

Switzerland 0

12 16 Per 100 000 hospital discharges

200

400 600 Per 100 000 hospital discharges

Note: Some of the variations across countries are due to different classification systems and recording practices. 95% confidence intervals represented by H. SDx: Secondary diagnoses adjustment. 1. The average number of secondary diagnoses is < 1.5.

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932704988

1 2 http://dx.doi.org/10.1787/888932705007

4.5.3. Postoperative pulmonary embolism or deep vein thrombosis, 2009 (or nearest year) SDx-adj. standardised rate

4.5.4. Postoperative sepsis, 2009 (or nearest year)

Age-sex standardised rate

SDx-adj. standardised rate

538

Belgium

708

Germany

203

541

335

Spain

285

705 754

Denmark

595

Germany

378 422

Denmark

674

France

506

Crude rate

858

215

Italy1

536 528

EU11

694

Sweden

926

582 389

Portugal

1 017 1 050

EU7

664 299

Finland1

680

1 062 1 099

Spain

697

Ireland

692 722 749

Sweden

France 391

Switzerland

200

1 224 1 863 1 951

Ireland 902

548 428

Norway

1 411

Belgium 820 812 780

United Kingdom

152

Switzerland

354

634

400 600 800 1 000 Rates per 100 000 hospital discharges

500

1 000 1 500 2 000 Rates per 100 000 hospital discharges

Note: Some of the variations across countries are due to different classification systems and recording practices. SDx: Secondary diagnoses adjustment. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932705045

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932705026

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

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PATIENT SAFETY • 4.6. OBSTETRIC TRAUMA

The patient safety indicators related to obstetric trauma flag cases of potentially preventable third- and fourth-degree perineal tears during vaginal delivery. Such tears extending to the perineal muscles, anal sphincter and bowel wall require surgical treatment after birth. Possible complications include continued perineal pain and anal incontinence. A recent study found that around 10% of women who had such tears will suffer from faecal incontinence initially (compared to 3% of women who do not have a tear). Almost 45% of women with initial symptoms had remaining problems after four to eight years (Sundquist, 2012). The proportion of deliveries involving higher degree lacerations is a useful indicator of the quality of obstetrical care. These types of tears are not possible to prevent in all cases, but can be reduced by employing appropriate labour management and care standards. A third- or fourth-degree trauma is more likely to occur in the case of first vaginal delivery, baby’s high birth weight, labour induction, occiput posterior position, prolonged second stage of labour and instrumental delivery. Obstetric trauma indicators have been used by the US Joint Commission as well as by different international quality initiatives analysing obstetric data (AHRQ, 2007). As the risk of a perineal laceration is significantly increased in instrument-assisted labour (vacuum, forceps), rates for this patient population are reported separately. Figures 4.6.1 and 4.6.2 show the variation in reported rates of obstetric trauma during vaginal delivery with and without instrument. The rate of obstetric trauma after vaginal delivery with instrument shows high variability among countries. Reported rates vary from below 3% (Slovenia, Portugal, France, Belgium, and Italy) to more than 10% (Sweden). Rates of obstetric trauma after vaginal delivery without instrument range from 0.2% to 3.2%. Denmark, Sweden and Switzerland stand out as having the highest reported rates for obstetric trauma without instrument. The lower rate of obstetric trauma in Finland compared to other Nordic countries (Denmark, Norway, and Sweden) may be explained by the variation in delivery method and episiotomy practice (Laine et al., 2009).

104

Furthermore, findings from a recent study showed that enhanced midwifery skills in managing vaginal delivery reduce the risk of obstetric anal sphincter injuries (Hals et al., 2010). There is a strong relationship between the two obstetric trauma indicators shown in Figures 4.6.1 and 4.6.2. Countries such as Belgium, Finland, France, Italy, Portugal, Slovenia and Spain report lower than EU average obstetric trauma rates for both indicators. Latvia, on the other hand, has high rates of trauma when an instrument was used but low rates when an instrument was not used during delivery. This makes it more difficult to draw any clear conclusions from these two indicators for Latvia.

Definitions and comparability The two obstetric trauma indicators are defined as the proportion of instrument assisted/non-assisted vaginal deliveries with third- and fourth-degree obstetric trauma codes in any diagnosis and procedure field. Therefore, any differences in the definition of principal and secondary diagnoses have no influence on the calculated rates. Several differences in data reporting across countries may influence the calculated rates of obstetric patient safety indicators. These relate primarily to differences in coding practice and data sources. Some countries report the obstetric trauma rates based on administrative hospital data and others based on obstetric register. There is some evidence that registries produce higher quality data and report a greater number of obstetric trauma events compared to administrative datasets (Baghestan et al., 2007). See box on “Definitions and comparability” for Indicator 4.5 “Procedural or postoperative complications”, for more information on patient safety indicators.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

PATIENT SAFETY

•

4.6. OBSTETRIC TRAUMA

4.6.1. Obstetric trauma, vaginal delivery with instrument, 2009 (or nearest year) Crude rates per 100 patients 12 11.1 9.8

7.7

7.5 6.6

6.3

6 4.7

3.8

2.1

1.7

1.6

3.4

3.3

3.1

2.8

2.6

3.6

i te

it z

ay 1

en 1 Sw

tv La

rm Ge

y an

k ar nm

la Ne

d1 an

nd Ir e

n Sp

ly It a

m iu Be

l ga r tu

1. Obstetric register data. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932705064

4.6.2. Obstetric trauma, vaginal delivery without instrument, 2009 (or nearest year) Crude rates per 100 patients 3.5 3.2

3.1

3.0 2.5 2.2

2.1

2.0

2.0 1.5

1.3

1.0 0.5

0.4

0.7

0.6

0.5

0.4

0.7

0.2

ay 1 Sw

it z

ed Sw

en 1

k nm

m ng Ki

d i te Un

an rm Ge

la er

s1 nd

nd la th Ne

Ir e

14 EU

ly It a

m iu lg Be

r tu

d1 Fi

n ai Sp

ia en ov Sl

an Fr

1. Obstetric register data. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932705083

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

105

CANCER CARE

• 4.7. SCREENING, SURVIVAL AND MORTALITY FOR CERVICAL CANCER

Cervical cancer is mainly the outcome of persistent infection with human papillomavirus (HPV), which accounts for approximately 95% of all cases (IARC, 1995; Franco et al., 1999). Every year 61 000 new cervical cancers are diagnosed in Europe (IARC, 2011). Precancerous changes can be detected and treated before progression to cancer occurs, making cervical cancer highly preventable. Population-based cervical screening programmes have been promoted by the Council of the European Union and the European Commission (European Union, 2003; EC, 2008c), but the periodicity and target groups vary among member states. Figure 4.7.1 shows cervical screening rates across European countries in the years 2000 and 2010 for women aged 20-69 years. In 2010, Latvia, Germany, the United Kingdom, and Norway reported coverage close to 80% of the target population. Whilst overall screening rates across the European Union improved slightly over the past decade, several countries, including Finland, Hungary, Iceland, Norway, the Slovak Republic and the United Kingdom witnessed a decline in screening rates between 2000 and 2010. Survival rates reflect both how early the cancer was detected and the effectiveness of the treatment. It is a key measure of the effectiveness of health care systems to treat potentially fatal diseases and track progress over time. Figure 4.7.2 shows a small gain in five-year cervical cancer survival rates in the European Union between 1997-2002 and 2004-09, although gains were not uniform across countries. Of the 11 EU member states reporting data in both periods, seven recorded modest gains in survival rates whereas four countries (Denmark, Finland, France and Germany) reported a small decline, although the reduction was not statistically significant. Norway reported the highest rates as well as the highest gain in cervical cancer survival, with 78.2% of patients surviving five years after diagnosis. Mortality rates reflect the effect of cancer care in past years, the impact of screening, improved diagnosis of early-stage cancers as well as incidence. Mortality rates for cervical cancer declined in most European countries between 2000 and 2010, apart from Bulgaria, the Former Yugoslav Republic of Macedonia and Croatia, Greece and Ireland (Figure 4.7.3). For some countries such as Lithuania and Romania, mortality rates remain well above the EU average. Since the development of a vaccine against some HPV types, vaccination programmes have been implemented in most EU countries. By May 2012, 17 out of 27 EU member

106

states had implemented rout ine H PV va ccina tion programmes. In most cases the vaccination programmes are financed by the national health systems. However, in Austria the vaccination is entirely covered by the recipient, and in Belgium and France recipients contribute 25% and 35% of the payment, respectively (ECDC, 2012b). Since its introduction, there has been an active policy and research debate about the impact of the vaccine on cervical cancer screening strategies (Goldhaber-Fiebert et al., 2008; Wheeler et al., 2009).

Definitions and comparability Screening rates for cervical cancer reflect the proportion of women who are eligible for a screening test and actually receive the test. As policies regarding screening periodicity and target population differ across countries, the rates are based on each country’s specific policy. Some countries ascertain screening based on surveys and others based on encounter data, which may influence the results. Survey-based results may be affected by recall bias. If a country has an organised programme, but women receive a screening outside the programme, rates may also be underreported. Survey data are reported only when programme data are not available. Relative cancer survival rates reflect the proportion of patients with a certain type of cancer who are still alive after a specified time period (commonly five years) compared to those still alive in absence of the disease. Relative survival rates capture the excess mortality that can be attributed to the diagnosis. For example, a relative survival rate of 80% does not mean that 80% of the cancer patients are still alive after five years, but that 80% of the patients that were expected to be alive after five years, given their age at diagnosis and sex, are in fact still alive. All the survival rates presented here have been agestandardised using the International Cancer Survival Standard (ICSS) population. The survival rates are not adjusted for tumour stage at diagnosis, hampering assessment of the relative impact of early detection and better treatment. See Indicator 1.5 “Mortality from cancer” for definition, source and methodology underlying the cancer mortality rates.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

CANCER CARE

•

4.7. SCREENING, SURVIVAL AND MORTALITY FOR CERVICAL CANCER

4.7.1. Cervical screening, percentage women screened aged 20-69, 2000 to 2010 (or nearest year) 2000 Austria

2010

1997-2002

78.7 82.0 78.5 78.2 78.4 76.5 74.9

Sweden1 Switzerland 2 Slovenia1

Sweden

65.6 68.1

Netherlands

63.1 67.0

Finland

67.9 66.3

72.1

Belgium

Finland1

71.1 70.3 69.8

Portugal

Greece 2

69.7

Denmark

France 2

Spain 2

EU24

63.3 62.9 62.0 62.5

Czech Republic

51.8

Luxembourg1

61.7 62.2

Austria

58.0 33.3

58.0 58.8

United Kingdom

47.4

Bulgaria 2

44.0

Italy1

54.3 57.6

Ireland

46.8

Estonia1

Latvia

48.7

40.0 28.4 23.7 23.2 22.9

Slovak Republic1

78.9 78.5 74.0

65.0

1. Programme.

68.8

Norway

78.2

Iceland

9.7

44.7

Malta

Norway1 Turkey

65.5 63.0

62.1

Malta 2

63.1 63.9

Germany

58.6 63.2

Belgium1

Iceland

65.4 64.3

France

66.3 65.6 66.1

Netherlands1

65.1

EU11

68.5 67.3

Denmark1

Hungary

65.3

69.1

Cyprus 2

Czech Republic

67.5 70.2

80.5

Germany2

Poland

2004-09

Slovenia

81.5

Latvia 2 United Kingdom

4.7.2. Cervical cancer five-year relative survival rate, 1997-2002 and 2004-09 (or nearest period)

75 100 Women screened (%)

67.3

2. Survey.

90 Survival (%)

Note: 95% confidence intervals represented by H.

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932705102

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932705121

4.7.3. Cervical cancer mortality, females, 2000 to 2010 (or nearest year) 2010

2000

13.4

14.8

Age-standardised rates per 100 000 females 16

11.6

5.8

7.1

6.9 7.5

7.5 6.3

6.9 6.1

5.7

4.1 3.2

3.3

1.4

2.3

2.8

3.6

4.0

3.6 3.9

3.6 3.0

3.0

3.3 2.5

2.4

2.5 2.5

3.3 2.3

4.9

5.8 1.5 1.5

2.7 2.2

2.6

2.0 1.9

1.8

1.5 1.7

2.1 1.4

0.7

0.9 0.8

1.0

2.2

2.4 2.1

4.1

4.8

5.1

5.9

7.4

7.3

9.0

9.3

tia

oa Cr

d an

of FY

ov Sl

a ni

an m

ic Bu

a Re

y ar

ia Hu

tv La

25 h

EU ec Cz

nd la

Ir e

ia Po

r tu

en ov

ria

k ar

m do

en ed

i te

ce an

xe Lu

ce Ne

ee Gr

ta al M

ly It a

Source: Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932705140

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

107

CANCER CARE

• 4.8. SCREENING, SURVIVAL AND MORTALITY FOR BREAST CANCER

Breast cancer is the most prevalent form of cancer among women, with 425 000 new cases diagnosed each year in Europe (IARC, 2011). Risk factors that increase a person’s chance of getting this disease include, but are not limited to, age, family history of breast cancer, oestrogen replacement therapy and alcohol. Annual incidence in Europe is expected to rise to 466 000 cases by 2020. Variation in breast cancer care across European countries is indicated by mammography screening rates in women aged 50-69 years, relative survival rates, and mortality rates. EU guidelines (EC, 2006) promote a desirable target screening rate of at least 75% of eligible women in European member states but in 2010 only three countries had reached this target. There is considerable uniformity amongst national breast screening programmes, in terms of the target age group and recommended time interval between screens. Participation, however, continues to vary considerably across European countries, ranging from 8% in Romania, 15% in Turkey and 16% in the Slovak Republic, to over 80% in Finland, Slovenia and the Netherlands (Figure 4.8.1). This variation may, in part, be explained by programme longevity, with some countries having well established programmes and others commencing programmes more recently (von Karsa et al., 2008). However, screening rates fell in a number of countries in the past decade including Norway and the United Kingdom. Rates in Hungary and the Slovak Republic have increased substantially, although they remain well below the EU average. Breast cancer survival rates reflect advances in public health interventions, such as greater awareness of the disease, screening programmes, and improved treatment. In particular, the introduction of combined breast conserving surgery with local radiation and advances in adjuvant and neoadjuvant therapy has increased survival as well as the quality of life of survivors (Mauri et al., 2008). Figure 4.8.2 shows that the average EU relative five-year breast cancer survival rate around the period 2004-09 was 82%. Between 1997-2002 and 2004-09, survival rates have improved in all countries. Survival rates around 2004-09 were highest in France, Finland, Belgium, Sweden, Norway and Iceland (with rates reaching 86% to 87%). Whilst survival

108

rates remain below 80% in Latvia, the Czech Republic and Slovenia, the data shows that for the latter two countries survival rates improved considerably over that period. Breast cancer mortality rates have declined in all EU member states over the past decade (Figure 4.8.3). The reduction in mortality rates is a reflection of improvements in early detection and treatment of breast cancer. Countries that reported relatively high mortality rates in 2000 recorded the biggest declines in breast cancer mortality. These countries include the Czech Republic, Estonia, Luxembourg, the Netherlands, Norway and the United Kingdom. Denmark also recorded substantial falls over the last decade but its mortality rate was the highest in 2010. The level of variation across the European Union has declined substantially over the period. In 2000, eight EU member states reported mortality rates higher than 30 deaths per 100 000 females, but in 2010 mortality rates were below this rate in all countries. Despite these gains over the past decade, around 129 000 deaths are caused by breast cancer each year in European countries.

Definitions and comparability Mammography screening rates reflect the proportion of eligible women who are actually screened. As policies regarding target age groups and screening periodicity differ across countries, the rates are based on each country’s specific policy. Some countries ascertain screening based on surveys and others based on encounter data, and this may influence results. Survey-based results may be affected by recall bias. If a country has an organised programme, but women receive a screen outside of the programme, rates may also be underreported. Survival rates are defined in Indicator 4.7 “Screening, survival and mortality for cervical cancer”. See Indicator 1.5 “Mortality from cancer” for definition, source and methodology underlying the cancer mortality rates.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

CANCER CARE

•

4.8. SCREENING, SURVIVAL AND MORTALITY FOR BREAST CANCER

4.8.1. Mammography screening, percentage of women aged 50-69 screened, 2000 to 2010 (or nearest year) 2000

2010

1997-2002

Finland Slovenia1 Netherlands1 Austria 2 Denmark1 United Kingdom1 Spain 2 Belgium 2 Ireland1 Estonia1 Cyprus 2 Italy1 Poland1 EU25 Luxembourg1 France 1 Germany1 Greece 2 Czech Republic1 Hungary1 Switzerland 2 Latvia 2 Malta 2 Bulgaria 2 Slovak Republic1 Romania 2

2004-09

85.5

France

83.5 87.0

85.1 80.5 82.1

Finland

84.2 86.3

80.2

Belgium

73.7 75.3 73.4

86.2 83.1 86.0

Sweden

73.3

82.7

Malta

72.7 79.5 84.4

Netherlands

71.6 62.0

74.5

Germany

59.4 59.2

83.3 76.9

EU11

82.5

57.1

Portugal

56.5 53.8 56.1

82.0 76.2

Denmark

82.0

54.5

81.3 79.3 81.2

Austria

49.5 26.7

75.0

United Kingdom

54.3 49.5

72.3

Ireland

49.1

80.3

44.8

70.8

Czech Republic

41.7 31.2

78.6 67.9

Slovenia

76.9

21.9 6.9

Latvia

16.0

73.0

8.0

Norway1 Iceland1 Turkey1

72.6

79.2

Iceland

14.8

82.4 86.5

Norway

61.0 60.0

1. Programme.

4.8.2. Breast cancer five-year relative survival rate, 1997-2002 and 2004-09 (or nearest period)

75 100 Women screened (%)

86.3

2. Survey.

80 100 Survival (%)

Note: 95% confidence intervals represented by H.

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932705159

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932705178

4.8.3. Breast cancer mortality, females, 2000 to 2010 (or nearest year) 2000

2010

45.6

Age-standardised rates per 100 000 females 50

28.1 27.6

25.5 23.7 19.0

20.0 20.1

24.8

26.8

26.2

25.8

25.5

25.2 25.2

25.0

28.9

33.5

35.0 30.5

33.0

30.5 27.1 24.8

24.5

24.4 24.2

28.3 24.0

26.3 23.6

27.7 23.0

27.6 22.8

23.2 22.6

22.0

21.5

21.1

23.0 21.2

26.7

27.9 21.6 21.1

20.6

22.2 20.0

21.4 19.8

21.9 19.4

23.6 19.1

20.5 17.7

30 25

30.7

25.9 23.0

36.7

15 10 5

tia

on ed

ac M

an el

s nd la

er th

nd la

Ir e

al M

ia Lu

tv La

ar ng

ni ua i te

ce an

ria

It a

st Au

ic bl

a ni

nl Fi

ce ee

bl pu

r tu

la Po

ar lg

n ai

Source: Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932705197

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

109

CANCER CARE

• 4.9. SCREENING, SURVIVAL AND MORTALITY FOR COLORECTAL CANCER

Colorectal cancer is the most commonly diagnosed form of cancer in Europe, with over 432 000 new cases diagnosed each year. By 2020, annual incidence is expected to rise to 502 000 cases (IARC, 2011). The annual incidence rate varies from 21 new cases per 100 000 population in Greece to 64 new cases in the Czech Republic. There are several factors that place certain individuals at increased risk for the disease, including age, the presence of polyps, ulcerative colitis, a diet high in fat and genetic background. Furthermore, males are at higher risk of developing colorectal cancer than females (IARC, 2011). The European Council has recommended implementation of population-based primary screening programmes using the faecal occult blood test (FOBT) for men and women aged 50-74 years (EC, 2010d). Organised screening programmes are being introduced or piloted in several countries and data on screening rates have become available for some European countries. Figure 4.9.1 shows colorectal screening rates using the FOBT test. The use of colonoscopy, which is part of several national policy cancer screening programmes for those with elevated risk, is not captured by these data (ECHIM, 2012). Based on survey data, participation is still relatively low across Europe when compared to long-standing screening programmes for cervical and breast cancer (see Indicators 4.7 and 4.8). Germany is a notable exception where screening rates have reached nearly 55% of the target population in 2010. The low rates observed in most countries may not only reflect the relatively recent implementation of many colorectal cancer screening programmes, but also the organisation and objectives of these programmes. The European Cancer Observer has previously noted that there was considerable variation in the way colorectal cancer screening programmes have been implemented across EU member states (von Karsa et al., 2008). Advances in diagnosis and treatment of colorectal cancer have increased survival over the last decade. There is compelling evidence in support of the clinical benefit of improved surgical techniques, radiation therapy and combined chemotherapy. Figure 4.9.2 shows the five-year relative survival rate following colorectal cancer diagnosis between 1997-2002 and 2004-09. In the 2004-09 period, the

110

highest survival rate was observed in Belgium, at nearly 65%. The figures indicate that survival rates improved in all eleven countries for which survival data was available for both periods, with countries such as Slovenia, the Czech Republic and Germany witnessing substantial gains in survival rates. Mortality rates reflect the effect of cancer care, screening and diagnosis as well as changes in incidence (Dickman and Adami, 2006). Between 2000 and 2010, average EU mortality rates fell from 22.2 to 20.5 per 100 000 population, although the trend was not uniform across all countries. Figure 4.9.3 reveals that out of 25 EU member states for which data were available, 15 countries saw a decrease whereas ten countries saw an increase in colorectal cancer mortality. It is noteworthy that the Czech Republic and Germany reported substantial declines in mortality rates and also have the highest screening rates in the European Union. Despite a decrease in their mortality rates for colorectal cancer over the past decade, Hungary continues to have the highest mortality rate for colorectal cancer, followed by the Slovak Republic and the Czech Republic. The number of annual deaths in Europe due to colorectal cancer is expected to rise from 212 000 in 2008 to 248 000 in 2020 (IARC, 2011).

Definitions and comparability Colorectal screening rates reflect the proportion of persons, aged 50-74, who have undergone a colorectal cancer screening test (faecal occult blood test) in the last two years. Screening rates are based on selfreported responses to the European Health Interview Survey (EHIS) and national health interview surveys. Survival rates are defined in Indicator 4.7 “Screening, survival and mortality for cervical cancer”. See Indicator 1.5 “Mortality from cancer” for definition, source and methodology underlying the cancer mortality rates. Deaths from colorectal cancer are classified to ICD-10 Codes C18-C21.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

CANCER CARE

•

4.9. SCREENING, SURVIVAL AND MORTALITY FOR COLORECTAL CANCER

4.9.1. Colorectal screening, percentage of people screened aged 50-74, 2010 (or nearest year) Germany

4.9.2. Colorectal cancer, five-year relative survival rate, 1997-2002 and 2004-09 (or nearest period) 1997-2002

54.2

Czech Republic

Belgium

25.3

France

18.6

Latvia

64.7 60.8

Malta

20.8

Slovak Republic

2004-09

Austria

57.1

France

58.5

63.1

13.7

EU15

Finland

58.9 61.8

Netherlands

57.9 61.0

Sweden

57.3 60.7

12.7

Bulgaria

11.4

Belgium

8.8

Slovenia

5.9

Cyprus Greece

51.8

EU10

4.8

Portugal

4.3

Slovenia

Hungary

53.3 60.4

Germany

57.4 57.4 45.5 55.8 50.1

Denmark

3.8

55.5 48.1

United Kingdom

Spain

53.3

3.5

49.0 52.9

Ireland Poland

3.5 41.1

Czech Republic Malta

49.6

2.6

Latvia

Romania

38.6

1.9 57.0

Norway Turkey

63.1

Iceland

3.2

66.1

40 60 % of people screened

Note: Data based on surveys in all countries.

Note: 95% confidence intervals represented by H.

Source: Eurostat Statistics Database (based on ECHI). 1 2 http://dx.doi.org/10.1787/888932705216

Source: OECD Health Data 2012.

100 Survival (%)

1 2 http://dx.doi.org/10.1787/888932705235

4.9.3. Colorectal cancer mortality, 2000 to 2010 (or nearest year) 2000

2010

18.0 17.1

16.6 18.8

22.1

25.3

28.1

26.5

23.8

20.6 22.3

21.3 22.3

20.5 21.6

20.3 21.8

21.9 21.4

20.7 21.1

20.3 20.5

20.0 20.6

15.5

22.2 20.5

19.5

23.7 19.3

20.8 19.1

20.8 18.4

17.7

18.6 17.0

17.8 17.2

19.2 16.8

14.9 13.1

10.0

12.0 12.1

16.4

18.6 16.6

22.2

23.7

25.4 25.6

28.0

28.2 29.0

32.7

34.4

36.1

38.5

Age-standardised rates per 100 000 population 45

10 5

tia

oa Cr

ic bl

ov Sl

l ga

ar nm

r tu

nd la

ni ua

th Li

a ni

la er

th Ne

tv La

ai Sp

25 EU

la Ir e

rm Lu

It a

i te

ria

st Au

ce ee

pr Cy

Source: Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932705254

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

111

CARE FOR COMMUNICABLE DISEASES â&#x20AC;˘ 4.10. CHILDHOOD VACCINATION PROGRAMMES

All EU member states have established childhood vaccination programmes. All programmes include vaccinations against diseases such as pertussis, diphtheria, tetanus and measles. Reviews of the evidence supporting the efficacy of vaccines against these diseases have concluded that the respective vaccines are safe and highly effective. For example, Peltola et al. (1994) reported that 12 years after the introduction of a comprehensive national vaccination programme in Finland measles had virtually been eradicated. Numerous studies have also shown that childhood vaccines can be highly cost-effective (e.g. Beutels and Gay, 2003; Banz et al., 2003; Lieu et al., 1994). Figures 4.10.1 and 4.10.2 show that the overall vaccination of children against diphtheria, tetanus and pertussis (whooping cough) as well as measles is generally high in European countries. In the European Union, more than 93% of children aged around 1 year receive the recommended vaccinations for these diseases. Whilst most countries have been able to increase or maintain their rate of childhood vaccinations over the last twenty years, some countries such as Austria and Denmark have witnessed a decline in coverage for diphtheria, tetanus and pertussis (see Indicator 1.11 for more information on pertussis notifications). The European Centre for Disease Control (ECDC) reports that Europe has not met its target of eliminating measles by 2010. Measles is a highly infectious disease that can lead to serious complications and, in rare cases, death. Compared to the five years prior, the numbers of measles cases were high in 2010 and 2011 with 30 265 and 30 567 cases, respectively. In 2010, the outbreak in the Roma community in Bulgaria accounted for most of the cases and in 2011, France accounted for 50% of cases. The ECDC argues that efforts to increase and maintain vaccination coverage at a high level will need to be strengthened in order to achieve the renewed target for eliminating measles by 2015 in the WHO European Region (ECDC, 2011). In 2009, there were 5 837 confirmed cases of hepatitis B virus infection reported in the European Union and EEA/EFTA member states. With 1.3 notifications per 100 000 population in EU member states, infection with the hepatitis B virus is relatively uncommon, but can cause acute or long-term illness, which is sometimes fatal (see Indicator 1.11 for more information on hepatitis B notifications). A vaccination for

112

hepatitis B has been available since 1982 and is considered to be 95% effective in preventing infection and its chronic consequences, such as cirrhosis and liver cancer. The WHO recommends that hepatitis B be part of national infant immunisation programme, or in countries with low levels of hepatitis B that routine hepatitis B vaccination should still be given high priority (WHO, 2004c). Figure 4.10.3 shows that the average percentage of children aged around 1 year who are vaccinated for hepatitis B across countries with national programmes is 95%. Countries such as Belgium, Germany and Turkey have been able to expand coverage in a relatively short period of time. Between 2000 and 2010, these countries increased coverage from less than 70% to 90% and more. A number of countries do not currently require children to be vaccinated against hepatitis B, or do not have routine programmes and consequently the rates for these countries are significantly lower compared to other European countries. For example, in Sweden, vaccination against hepatitis B is not part of the general vaccination programme, and is only recommended to specific risk groups. In France, hepatitis B vaccination has been controversial but vaccination coverage among children has increased in recent years. Alongside the systematic introduction of hepatitis B vaccinations in many countries, there has been decreasing trend of hepatitis B cases, with EU-wide surveillance showing a fall of 17% in the number of cases between 2006 and 2009 (ECDC, 2011).

Definitions and comparability Vaccination rates reflect the percentage of children at either age 1 or 2 who receive the respective vaccination in the recommended timeframe. Childhood vaccination policies differ slightly across countries. Thus, these indicators are based on the actual policy in a given country. Some countries administer combination vaccines (e.g. DTP for diphtheria, tetanus and pertussis) while others administer the vaccinations separately. Some countries ascertain vaccinations based on surveys and others based on encounter data, which may influence the results.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

CARE FOR COMMUNICABLE DISEASES

4.10.1. Vaccination rates for diphteria, tetanus and pertussis, children aged around 1, 2010 Cyprus Luxembourg Belgium France Greece Poland Slovak Republic Czech Republic Finland Hungary Portugal Sweden Netherlands Spain Romania United Kingdom Slovenia Italy EU27 Lithuania Ireland Bulgaria Estonia Germany Denmark Latvia Austria Malta

4.10. CHILDHOOD VACCINATION PROGRAMMES

4.10.2. Vaccination rates for measles, children aged around 1, 2010 Greece Hungary Finland Czech Republic Slovak Republic Poland Bulgaria Sweden Portugal Lithuania Germany Luxembourg Netherlands Slovenia Estonia Romania Spain Belgium EU27 United Kingdom Latvia Italy France Ireland Cyprus Denmark Austria Malta

99 99 99 99 99 99 99 99 99 99 98 98 97 97 97 96 96 96 95 95 94 94 94 93 90 89 83 76

99 99 98 98 98 98 97 96 96 96 96 96 96 95 95 95 95 94 93 93 93 90 90 90 87 85 76 73

FYR of Macedonia Turkey Croatia Serbia Iceland Norway Switzerland Montenegro

Turkey Iceland Croatia Switzerland FYR of Macedonia Montenegro Norway Serbia

•

96 96 95 95 94 93 91

100 % of children vaccinated

98 97 95 95 93 93 90 90

Source: OECD Health Data 2012 (based on WHO/UNICEF data). 1 2 http://dx.doi.org/10.1787/888932705273

100 % of children vaccinated

Source: OECD Health Data 2012 (based on WHO/UNICEF data). 1 2 http://dx.doi.org/10.1787/888932705292

4.10.3. Vaccination rates for hepatitis B, children aged around 1, 2010 Required and/or routine immunisation

Not required and/or not routinely provided by age 2

% 100

42 83

ia Se

te on

y M

ke Tu r

tia

ed Sw

an Fr

ria st Au

tv La

ua th Li

a ni to Es

nd la Ir e

ur bo

m xe

ce ee Gr

ar lg

18 EU

It a

pr Cy

ai Sp

r tu

iu lg Be

an m

la Po

bl pu

Re ak

ec Cz

Note: OECD average only includes countries with required or routine immunisation. Source: OECD Health Data 2012 (based on WHO/UNICEF data).

1 2 http://dx.doi.org/10.1787/888932705311

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

113

CARE FOR COMMUNICABLE DISEASES • 4.11. INFLUENZA VACCINATION FOR OLDER PEOPLE

Influenza is a common infectious disease and affects people of all ages. WHO Europe reports that each year seasonal influenza affects between 5 to 15% of the population in the northern hemisphere. Most people with the illness recover quickly, but elderly people and those with chronic medical conditions are at higher risk of complications and even death. In any particular year, influenza can have a substantial impact on the health of the population and the health care system (Nicholson et al., 2003; Simonsen et al., 2000). Vaccines have been used for more than 60 years, and provide a safe and effective means of preventing influenza, and reducing the impact of epidemics. Among the elderly, appropriate influenza vaccines will, in general, reduce the risk of serious complications or death by 70-85% (Ryan, 2006). In 2003, all World Health Assembly (WHA) countries, including all EU member states, committed to the goal of attaining vaccination coverage of the elderly population of at least 50% by 2006 and 75% by 2010 (WHA, 2003; Mereckiene et al., 2008). Figure 4.11.1 shows that around 2010, across 22 EU member states for which data was available, the average influenza vaccination rate for people aged 65 and over was 45.3%. Vaccination rates across Europe range from 1% in Estonia to 74% in the Netherlands. Whilst there is still some uncertainty about the reasons for the cross-national differences in vaccination rates, studies have highlighted that the lack of public health insurance coverage may be an important determinant in explaining low uptake in some countries (Mereckiene et al., 2008; Kroneman et al., 2003; Kunze et al., 2007). Studies have also shown that personal contact with a doctor is a key determinant of uptake, and that better information through mass-media campaigns, patient and provider education initiatives, and recall and reminder systems can play an important role in improving vaccination rates (Kohlhammer et al., 2007). Figure 4.11.2 indicates that between 2000 and 2005, vaccination rates across the European Union increased from 45% to 54% of the elderly population but fell between 2005 and 2010. There appears to be no uniform trend across Europe. Some countries such as France and the Netherlands have maintained their vaccination rates over the decade, countries such as Belgium and Portugal have seen a rise in the rate, and a large number of countries witnessed their rates increase between 2000 and 2005 but then fall again in 2010. No country attained the 75% coverage target in 2010. In late 2009, the Health Ministers of the European Union

114

adopted an EU Council Recommendation to reach the target of 75% vaccination coverage amongst the elderly as early as possible and preferably by the 2014-15 winter season. The recommendation also proposed that the target of 75% coverage should, if possible, be extended to people with chronic conditions. In June 2009, the WHO declared the first influenza pandemic since 1968-69 (WHO, 2009b). Within 23 weeks of the first diagnosis of the H1N1 influenza virus (also referred to as “swine flu”), there were over 53 000 confirmed cases across all EU member states, Iceland, Liechtenstein and Norway (ECDC, 2011). The estimated infection attack rates remained low in the overall population but were high amongst young people aged 5-19 years. Following the development, testing and production of a H1N1 vaccine, most EU member states included the 2009-10 seasonal influenza vaccine and the pandemic vaccine into their influenza vaccination programmes (Valenciano et al., 2011). Despite the worldwide focus on H1N1, numerous studies have shown that vaccination rates against the virus were lower than expected in a large number of countries (Poland, 2011; Mereckiene et al., 2012). In part, this may be due to the easing of concerns about the threat of H1N1 amongst the general population by the time the vaccine became available. The most important determinant for individuals to take-up H1N1 vaccine was previous exposure to seasonal flu vaccine, leading some researchers to argue that higher vaccination rates for seasonal flu may help uptake during potential future pandemics (Poland, 2011; Nguyen et al., 2011; Bish et al., 2011).

Definitions and comparability 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.

HEALTH AT A GLANCE: EUROPE 2012 © OECD 2012

it z er la

35 35

37 37

51 59

2005

36 36

ak ec

ov Cz

it z

ria

ce an st

k 21 ee nl Au

ur nm

r tu

1.0

12.1

29.5

22.1

23.8

18.0

ria

30 25

It a

Ir e

45.6

36.1

46.0

41.4

64.0

65.0

63.8

61.1

74.0

70.3

66.0

62.4

56.9

52.2

46.7

45.3

39.0

63 61

•

42 42

2000

r tu

63 64

64 65

i te

It a

70 65 68 66

76 77 74

% 100

Ir e

i te

CARE FOR COMMUNICABLE DISEASES 4.11. INFLUENZA VACCINATION FOR OLDER PEOPLE

% 100

4.11.1. Vaccination rates for influenza, population aged 65 and over, 2010 (or nearest year)

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932705330

4.11.2. Trends in vaccination rates for influenza, population aged 65 and over, 2000-10 (or nearest year) 2010

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932705349

115

Health at a Glance: Europe 2012 ÂŠ OECD 2012

Chapter 5

Health expenditure and financing

5.1. Coverage for health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 5.2. Health expenditure per capita. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 5.3. Health expenditure in relation to GDP . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 5.4. Health expenditure by function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 5.5. Pharmaceutical expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 5.6. Financing of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 5.7. Trade in health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

117

5.1. COVERAGE FOR HEALTH CARE

Health care coverage enables access to medical goods and services and provides financial security against unexpected or serious illness. However, the share of the population with health insurance coverage – be it public or private – is an imperfect indicator of accessibility, since the range of services covered and the degree of cost-sharing applied to those services vary across countries. Most European countries have achieved universal (or near-universal) coverage of health care costs for a core set of services, which usually include consultations with doctors, tests and examinations, and hospital care (Figure 5.1.1). In most countries, dental care and the purchase of prescribed pharmaceuticals are also at least partially covered (Paris et al., 2010). Two European countries do not yet have universal health coverage. In Cyprus, an estimated 83% of the population are entitled to public health services, although many currently seek medical care in the private sector and pay out-of-pocket. A new National Health Insurance System has been proposed to modernise public health care and extend coverage (Cyprus National Reform Programme, 2012; Theodorou et al., 2012). In Turkey, public coverage has increased rapidly since reforms to implement universal health insurance began in 2003 under the ten-year Health Transformation Programme (OECD, 2008b; Tatar et al., 2011). The population covered rose from 70% in 2002 to 83% in 2010 and is continuing to move towards full coverage estimated to be 98% in 2012. Basic primary health coverage, whether provided through public or private insurance, generally covers a defined “basket” of benefits, in many cases with costsharing. In some countries, additional health coverage can be purchased through private insurance to cover any costsharing left after basic coverage (complementary insurance), add additional services (supplementary insurance) or provide faster access or larger choice to providers (duplicate insurance). In most European countries, only a small proportion of the population has an additional private health insurance. But in six countries, half or more of the population had a private health insurance in 2010 (Figure 5.1.2).

118

In France, nearly all the population (96%) has a complementary private health insurance to cover cost-sharing in the social security system. A large proportion of the population in Belgium, Luxembourg and Slovenia also make use of complementary health insurance. The Netherlands has the largest supplementary market (89% of the population), whereby private insurance pays for prescribed pharmaceuticals and dental care that are not publicly reimbursed. Duplicate markets, providing faster private-sector access to medical services where there are waiting times in public systems, are largest in Ireland (50%). The population covered by private health insurance has been growing over the past decade in some countries including France, Belgium and Germany, but not in Ireland and Luxembourg (Figure 5.1.3). The importance of private health insurance is not linked to a countries’ economic development. Other factors are more likely to explain market development, including the history of health care financing arrangements and government interventions directed at private health insurance markets (OECD, 2004).

Definition and comparability Coverage for health care is the share of the population receiving a defined set of health care goods and services under public programmes and through private health insurance. It includes those covered in their own name and their dependents. Public coverage refers both to government programmes, generally financed by taxation, and social health insurance, generally financed by payroll taxes. Take-up of private health insurance is often voluntary, although it may be mandatory by law or compulsory for employees as part of their working conditions. Premiums are generally non-income-related, although the purchase of private cover can be subsidised by the government.

5.1. COVERAGE FOR HEALTH CARE

5.1.1. Health insurance coverage for a core set of services, 2010 (or nearest year) Total public coverage United Kingdom Sweden Slovenia Romania Portugal Malta Lithuania Latvia Italy Ireland Hungary Greece Germany Finland Denmark Czech Republic Bulgaria France Austria Spain Belgium Netherlands Luxembourg Poland Slovak Republic Estonia Cyprus

5.1.2. Private health insurance coverage, by type, 2010 (or nearest year)

Primary private health coverage

Primary

Complementary

Supplementary

Duplicate

100.0

France

100.0

96.0

100.0

Netherlands

100.0

89.0

100.0 100.0

Belgium

100.0

78.9

100.0

Slovenia

100.0

73.1

71.1

100.0 100.0

Luxembourg

55.2

100.0 89.1

10.9

Ireland

100.0

49.8

100.0

Austria

100.0

33.9

100.0 99.9

Germany

99.3

20.2

10.9

31.1

99.2 99.0

Spain

19.7

Portugal

19.6

Denmark

19.6

98.9 97.6 97.5 94.8 93.7 83.0

Switzerland Serbia Norway Montenegro FYR of Macedonia Croatia Iceland Turkey

100.0 100.0

Switzerland

100.0

29.5

100.0

Turkey

100.0

2.9

100.0 0.2

99.8

Iceland

0.2

82.9

90 100 Percentage of total population

Source: OECD Health Data 2012; WHO Europe (2012). 1 2 http://dx.doi.org/10.1787/888932705368

60 80 100 Percentage of total population

Note: Private health insurance can fulfil several roles. In Denmark, for example, it can be both complementary and supplementary. Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932705387

5.1.3. Trends in private health insurance coverage, 2000 to 2010 Belgium

% 100

France

Germany

Ireland

Luxembourg

20 2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Source: OECD Health Data 2012.

1 2 http://dx.doi.org/10.1787/888932705406

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

119

5.2. HEALTH EXPENDITURE PER CAPITA

There are large variations in the level and in the rate of growth of health spending across European countries. Health expenditure per capita tends to be related with overall income per capita. Hence, it is not surprising that Norway and Switzerland are the two European countries that spent the most on health in 2010, with spending of over EUR 4 000 per person (Figure 5.2.1). Among EU member states, the Netherlands (EUR 3 890), Luxembourg (EUR 3 607) and Denmark (EUR 3 439) were the highest spenders, exceeding by a wide margin the EU average (EUR 2 171). Romania and Bulgaria were the lowest spending countries among EU members. Health spending per capita was also relatively low in the Former Yugoslav Republic of Macedonia and Turkey. Growth in health spending per capita slowed or fell in real terms in 2010 in almost all European countries, reversing a trend of steady increases in many countries. Health spending per capita had already started to fall in 2009 in some countries that were hardest hit by the economic crisis (e.g. Estonia and Iceland), but this was followed by further and deeper cuts in 2010. On average across EU member states, health spending per capita increased by 4.6% per year in real terms between 2000 and 2009, but this was followed by a reduction of 0.6% in 2010 (Figure 5.2.2). While government health spending tended to be maintained at the start of the economic crisis, cuts in spending really began to take effect in 2010 in response to budgetary pressures and the need to reduce large deficits and debts. In Ireland, cuts in government spending drove total health spending per capita down by nearly 8% in 2010, compared with an average growth rate of 6.5% per year between 2000 and 2009. In Estonia, expenditure on health per capita dropped by 7.3% in 2010 due to reductions in both public and private spending, following an average annual growth rate of 7.2% between 2000 and 2009. In Greece, health spending per capita fell by 6.7% in 2010, after a yearly growth rate of 5.7% during the 2000-09 period. In several other countries (e.g. in Belgium, Finland, the Netherlands, Poland, the Slovak Republic and Sweden), there was a marked slowdown in the rate of growth of health spending per capita, although it remained positive. Reductions in public spending on health were achieved through a range of measures. In Ireland, most of the reductions have been achieved through cuts in wages and a reduction in the number of healthcare workers as well as the fees paid to professionals and pharmaceutical companies. Estonia cut administrative costs in the Ministry of Health and the prices of publicly-reimbursed health services. Investment in health infrastructure has also been put on hold in a number of countries, including the

120

Czech Republic, Estonia, Iceland and Ireland, while gains in efficiency have been pursued through mergers of hospitals or accelerating the move from inpatient care in hospital to outpatient care and day surgery. Other measures have been introduced to make people pay more out of their pockets. For example, Ireland increased the share of direct payments by households for prescribed pharmaceuticals and appliances, while the Czech Republic increased users’ charges for hospital stays. As a result of the slowdown or negative growth in health spending per capita in 2010, the percentage of GDP devoted to health stabilised or declined slightly in many EU member states (see Indicator 5.3 “Health expenditure in relation to GDP”).

Definition and comparability Total expenditure on health measures the final consumption of health goods and services (i.e. current health expenditure) plus capital investment in health care infrastructure, as defined in the System of Health Accounts manual (OECD, 2000; OECD, Eurostat and WHO, 2011). This includes spending by both public and private sources on medical services and goods, public health and prevention programmes, and administration. The vast majority of countries now produce health spending data according to the boundaries and definitions proposed in the System of Health Accounts (SHA) manual. The comparability of the functional breakdown of health expenditure data has improved over recent years. However, limitations remain, as some countries have not yet implemented the SHA classifications and definitions. Even among those countries that are submitting data according to the SHA, the comparability of data sometimes needs to be improved. Different practices regarding the treatment of capital expenditure and the inclusion of long-term care in health or social expenditure are some of the main factors affecting data comparability. Countries’ health expenditures are converted to a common currency (Euro) and are adjusted to take account of the different purchasing power of the national currencies, in order to compare spending levels. Economy-wide (GDP) PPPs are used to compare relative expenditure on health in relation to the rest of the economy.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

it z la

tia

-7.1

-1.2

-2.0

2.1

3.4

3.1

2.9

2.0 1.4

1.6

4.2

3.5 3.6

2.0 2.7

2.4

3.1 2.2

2.0

1.2

1.3 1.0

0.8

3.9

3.8

5.6

5.5

7.1

10.9

2000-09

1.8

2.2

N S w or w i t z ay er la Ic nd el a Cr n d oa ti M Se a on r b te ia ne FY g R of Tu ro M rk ac ey ed on ia

1 068

899 714 619

1 152 902

677

745

821

972

995

1 869

1 758

1 450 1 231

2 524

2 171 2 097

1 783

1 614

2 282 2 244

3 052

2 862

2 504 2 345

3 337 3 058

2 894

2 636

3 439 3 383

4 156 4 056

Capital expenditure

It a

0.5

0.4

0.2

0.1

2.7

4.9

4.6

4.1

3.9

3.2

1 000

r tu

-0.2

-0.5

-0.6

-0.9

-2.0

-2.1

6.0

8.9

3 890 3 607

Current expenditure on health

ria

-4.4

-5.0

5.7

2 000

EU ng

-6.7

-7.3

-5

7.2

6.5

i te

-7.9

3 000

-10

Ne t L u h er xe l a n m ds bo D e ur g 1 nm a Au rk s Ge tr ia rm an Fr y an Be ce lg i S w um ed Un i t e Ir e e n d K i land ng do Fi m nl an d Sp ai n It a Gr l y ee ce EU Po 2 7 r tu Sl g a l ov en C y ia p Sl ru ov s a M C z k R alt a ec ep h ub Re lic pu Hu blic ng a Po r y la Es nd t L i oni th a ua ni La a Bu t v i a lg Ro a r i a m an ia

4 000

Ir e

5.2. HEALTH EXPENDITURE PER CAPITA

5.2.1. Health expenditure per capita, 2010 (or nearest year)

EUR PPPs 5 000 Total (no breakdown)

1. Health expenditure is for the insured population rather than resident population.

Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Health Expenditure Database.

1 2 http://dx.doi.org/10.1787/888932705425

5.2.2. Annual average growth rate in health expenditure per capita, in real terms, 2000 to 2010 (or nearest year)

Annual average growth rate (%) 15 2009-10

Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Health Expenditure Database.

1 2 http://dx.doi.org/10.1787/888932705444

121

5.3. HEALTH EXPENDITURE IN RELATION TO GDP

In 2010, EU member states devoted on average (unweighted) 9.0% of their GDP to health spending in 2010 (Figure 5.3.1), up significantly from 7.3% in 2000, but down slightly from the peak of 9.2% reached in 2009 following the economic crisis which started in many countries in the middle of 2008. In many countries, public spending on health was maintained in 2009 while GDP was falling strongly, but this was followed in 2010 by the implementation of a range of measures to reduce government health spending as part of broader efforts to reduce large budgetary deficits and debts (see Indicator 5.2). The Netherlands had the highest share of its GDP allocated to health in 2010 (12%), followed by France and Germany (both at 11.6%). This share remains well below the United States where health expenditure accounted for 17.6% of GDP in 2010. The share of health spending in GDP was lowest in Romania and Turkey, at around 6%. With the exception of Cyprus, public funding remains the main source of financing of health expenditure in all EU member states, with close to three-quarters of all spending being paid by public sources (see Indicator 5.6). The ranking of countries in terms of public expenditure on health as a share of GDP is not very different from total expenditure on health. The Netherlands (9.6%) and Denmark (9.5%) had the highest share of public expenditure on health to GDP, followed by France (9.0%) and Germany (8.9%). Cyprus had the lowest share of public spending on health to GDP (3.2%), followed by Bulgaria (4.0%) and Latvia (4.1%). For a more complete understanding of the level of health spending, the health spending to GDP ratio should be considered together with health spending per capita (see Indicator 5.2). Countries having a relatively high health spending to GDP ratio might have relatively low health expenditure per capita, and the converse also holds. For example, Belgium and Portugal both spent around 10.5% of their GDP on health in 2010; however, per capita spending (adjusted to EUR PPP) was nearly 50% higher in Belgium (see Figure 5.2.1). Changes in the ratio of health spending to GDP are the result of the combined effect of growth in both GDP and health expenditure. Between 2000 and 2010, the annual average growth in health expenditure per capita in real

122

terms was about 4% on average in EU member states, nearly two-times greater than the growth rate in GDP per capita. With the exception of Bulgaria, Iceland and Luxembourg, annual growth in health spending outpaced GDP growth in all European countries over the past decade (Figure 5.3.2). This explains why the share of GDP allocated to health increased from 7.3% to 9.0% during that period. In France and Germany, the health spending to GDP ratio increased from just over 10% in 2000 to 11.6% in both countries in 2010 (Figure 5.3.3). Health spending per capita grew slightly faster in Germany than in France over the past decade, but so did GDP per capita. The share of GDP was relatively stable in both countries between 2003 and 2008, but it then increased by 1 percentage point in 2009 as health spending continued to grow while GDP fell in both countries. In the United Kingdom, the health spending share of GDP used to be below the EU average, but since 2006, it is now above average. As in many other European countries, the share of health spending allocated to GDP in the United Kingdom increased by a full percentage point in 2009 following the financial and economic crisis, but came down slightly in 2010.

Definition and comparability See Indicator 5.2 for the definition of total health expenditure. Gross domestic product (GDP) = final consumption + gross capital formation + net exports. Final consumption of households includes goods and services used by households or the community to satisfy their individual needs. It includes final consumption expenditure of households, general government and non-profit institutions serving households. In countries, such as Ireland and Luxembourg, where a significant proportion of GDP refers to profits exported and not available for national consumption, gross national income (GNI) may be a more meaningful measure than GDP.

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

5.3. HEALTH EXPENDITURE IN RELATION TO GDP

5.3.1. Total health expenditure as a share of GDP, 2010 (or nearest year) Public

Private

11.4

7.1

7.8

9.3

9.4

9.1

10.4

6.1

6.3

6.0

7.0

6.8

7.2

7.0

7.5

7.4

7.8

8.6 7.9

8.9

9.0

9.2

9.6

9.3

9.6

10.2 9.6

10.7

10.5

11.0

11.6

11.1

11.6

12.0

% GDP 14

6 4 2

rm De any nm a Au rk st Po r i a r tu Be gal lg iu m Gr 2 ee ce Sp ai Un i te S we n d K i den ng do m It a Sl o v Ir e l y ak la Re nd pu b Sl lic ov en ia EU 27 Fi nl an d Lu M xe a l m ta bo u C z Hu r g 3 ec ng h Re ar y pu bl C y ic pr Bu us lg ar Po i a la Li nd th ua ni a La tv i a Es to Ro n i a m an ia Sw it z er la n Se d rb No ia rw ay I M c el a on nd te ne FY gr R o f Cr o o M ac atia ed on i Tu a rk ey

la er th Ne

1. In the Netherlands, it is not possible to clearly distinguish the public and private share related to investments. 2. Public and private expenditures are current expenditures (excluding investments). 3. Health expenditure is for the insured population rather than resident population. Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Health Expenditure Database.

1 2 http://dx.doi.org/10.1787/888932705463

5.3.2. Annual average growth in health expenditure and GDP per capita, in real terms, 2000-10 (or nearest year)

5.3.3. Total health expenditure as a share of GDP, 2000-10, selected EU member states France United Kingdom

Germany

Italy EU27

Annual average growth in health expenditure per capita (%) 7 LTU TUR POL 6 MNE EST ROU NLD 5 IRL CZE GBR GRC BGR 4 FIN ESP EU SVN SWE MLT 3 DNK BEL HUN NOR DEU LVA HRV CYP FRA 2 AUT PRT CHE ITA 1 LUX ISL 0 0 1 2 3 4 5 6 7 Annual average growth in GDP per capita (%)

% GDP 12

Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Health Expenditure Database. 1 2 http://dx.doi.org/10.1787/888932705482

Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Health Expenditure Database. 1 2 http://dx.doi.org/10.1787/888932705501

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

6 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

123

5.4. HEALTH EXPENDITURE BY FUNCTION

In 2010, curative and rehabilitative care provided either as inpatient care (including day care) or outpatient care, accounted for 61% of current health spending (excluding capital investment) on average across EU member states (Figure 5.4.1). A further 23% of health spending was allocated to medical goods (including mainly pharmaceuticals, which accounted for 19% of total health spending), 10% to longterm care and the remaining 6% on collective services including public health services and administration. The allocation of spending by type of care varies significantly across European countries. Spending for inpatient care, day care and outpatient care depends on the institutional arrangements for health care provision. In Portugal and Sweden, for example, the majority of curative and rehabilitative spending is on outpatient care, with relatively low levels of hospital inpatient activity. In some other countries, such as Bulgaria and Romania, inpatient activity (including day care) plays a more dominant role accounting for over two-thirds of all curative and rehabilitative care expenditure. The other major category of health expenditure is on medical goods, mainly pharmaceuticals (see Indicator 5.5). In Hungary and the Slovak Republic, expenditure on medical goods is in fact a larger spending category than inpatient care or outpatient care, representing 37% of current health expenditure. In Norway and Switzerland, on the other hand, spending on medical goods represents only 12% of total health spending. Differences in the consumption pattern of pharmaceuticals and relative prices play a role in explaining some of the variations between countries. There are some large differences between countries in their expenditure on long-term care. Countries such as Denmark, the Netherlands and Norway, which have established formal arrangements for the elderly and the dependent population, allocate more than 20% of current health spending to long-term care. In countries with less comprehensive formal long-term care services such as Portugal, the expenditure on long-term care accounts for a much smaller share of total spending. Figure 5.4.2 compares the real growth rates in inpatient and outpatient spending over the last decade. With inpatient care being highly labour and capital intensive and, therefore, expensive, certain high-income countries with developed health systems have sought to reduce the share of spending in hospitals by shifting to more outpatient and home based care and improving primary care to prevent hospital admissions in the first place. In Iceland, spending on inpatient services decreased by over 3% per year on average between 2000 and 2010, while outpatient care grew on average at an annual rate of 3.2%. In other countries such as the Czech Republic and Poland, spending for both inpatient and outpatient care increased strongly

124

over the past decade, but the growth in inpatient services exceeded outpatient care. On average across EU member states, the growth in inpatient spending was slightly above the growth in outpatient spending during the past decade. Figure 5.4.3 shows the share of health expenditure allocated to organised public health and prevention programmes. On average, EU member states allocated less than 3% of their spending on health to prevention activities such as vaccination programmes and public health campaigns on alcohol abuse and smoking. However, where such initiatives are carried out at the primary care level, such as in Spain, the prevention function might not be captured separately and may be included under spending on curative care. Countries adopting a more centralised approach to public health and prevention campaigns are better able to identify spending on such programmes.

Definition and comparability The System of Health Accounts (OECD, 2000; OECD, Eurostat and WHO, 2011) defines the boundaries of the health system. Current health expenditure comprises personal health care (curative care, rehabilitative care, long-term care, ancillary services and medical goods) and collective services (public health services and health administration). Curative, rehabilitative and long-term care can also be classified by mode of production (inpatient, day care, outpatient and home care). Day care comprises health care services delivered to patients who are formally admitted to hospitals, ambulatory premises or self standing centres but with the intention to discharge the patient on the same day. An outpatient is not formally admitted to a facility (physicianâ&#x20AC;&#x2122;s private office, hospital outpatient centre or ambulatory-care centre) and does not stay overnight. Concerning long-term care, only the health aspect is normally reported as health expenditure. This is the reason why some countries with comprehensive long-term care packages focusing on social care might be ranked surprisingly low when analyzing long-term care expenditure based on SHA data. Factors limiting the comparability across countries include estimations of long-term care expenditure. Also, expenditure in hospitals may be used as a proxy for inpatient care services, although hospital expenditure may include spending on outpatient, ancillary, and in some cases drug dispensing services (Orosz and Morgan, 2004).

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

5.4. HEALTH EXPENDITURE BY FUNCTION

5.4.1. Current health expenditure by function of health care, 2010 (or nearest year) Countries are ranked by inpatient curative care as a share of current expenditure on health Inpatient (including day care) 1

% 100

Outpatient 2 6

Long-term care

Medical goods 7

11 20

70 60

10 9

22 37

20 24

Collective services

4 28

28 18

37 27

30 20

it z

ay No

bl pu

Sp ov

n ai

ng Hu

g ur bo

r tu

ed Sw

an rm

iu lg

to Es

ua th

pu Re

ov Sl

ia tv

s nd

ria

la er

nd la

st Au

an Fr

m Ro

1. Refers to curative and rehabilitative inpatient and day care provided in hospitals, day surgery clinics, etc. 2. Refers to curative and rehabilitative care in doctorsâ&#x20AC;&#x2122; offices, clinics, outpatient departments of hospitals, home care and ancillary services. Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932705520

5.4.2. Growth in inpatient and outpatient expenditure per capita, in real terms, 2000-10 (or nearest year) Inpatient1

Outpatient 2

Poland

8.1

5.3

Czech Republic

7.0

4.2

Netherlands

5.7

1.2

Slovenia

4.0

2.7

3.7

Estonia

7.1

Denmark

3.4

2.6

3.3 4.9

Finland EU15

3.2

3.0

Spain

2.8

2.5

Austria

2.1

1.6

2.0 3.2

Sweden France

1.9

1.1

1.8 2.7 1.8 2.2 0.7 3.3 0.4 1.1

Hungary Germany Portugal Luxembourg

Norway

2.4 1.4 2.5

Switzerland -3.1

Iceland -5

2.6

3.2

5 10 Annual average growth rate (%)

1. Including day care. 2. Including home care and ancillary services. Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932705539

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

5.4.3. Expenditure on organised public health and prevention programmes, 2010 (or nearest year) Romania Finland Slovak Republic Netherlands Hungary Slovenia Sweden Bulgaria Germany Latvia EU24 Estonia Czech Republic Spain Denmark Portugal France Poland Belgium Luxembourg Austria Malta Lithuania Cyprus Italy

6.2 5.4 5.3 4.8 4.5 3.8 3.6 3.5 3.2 3.1 2.9 2.7 2.5 2.3 2.3 2.1 2.1 2.1 2.0 1.9 1.8 1.3 0.8 0.5 0.5

Serbia Norway Switzerland Iceland Croatia

6.3 2.5 2.4 1.5 0.7

6 8 % current expenditure on health

Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Health Expenditure Database. 1 2 http://dx.doi.org/10.1787/888932705558

125

5.5. PHARMACEUTICAL EXPENDITURE

Pharmaceutical expenditure accounted for almost a fifth (19%) of all health expenditure on average in EU member states in 2010, making it the third biggest spending component after inpatient and outpatient care. Increased spending on pharmaceuticals has contributed to the overall rise in total health expenditure over the past decade, although the growth rate turned negative in several countries in 2010. The relationship between pharmaceutical expenditure and other health expenditure is a complex one, in that increased expenditure on pharmaceuticals to tackle different diseases may reduce the need for costly hospitalisations and interventions now or in the future. The total pharmaceutical bill across the European Union reached more than EUR 190 billion in 2010. However, there are wide variations in pharmaceutical spending per capita across countries, reflecting differences in volume, structure of consumption and pharmaceutical prices (Figure 5.5.1, left panel). At EUR 528, Ireland spent more on pharmaceuticals than any other European country on a per capita basis. This is 50% above the average across EU member states of EUR 349. Other countries with relatively high pharmaceutical expenditure include Germany (EUR 492), Belgium (EUR 479) and France (EUR 468). At the other end of the scale, Romania spent only EUR 164 per capita. Denmark, Estonia, Latvia and Poland are also among the countries that have relatively low pharmaceutical spending per capita, at less than 70% of the EU average. Pharmaceutical spending accounted for 1.6% of GDP on average across EU member states, ranging from below 1% in countries such as Denmark, Luxembourg and Norway, to more than 2% in Bulgaria, Hungary, the Slovak Republic and Serbia (Figure 5.5.1, right panel). The economic crisis in many European countries has had a significant effect on pharmaceutical spending (Figure 5.5.2). Between 2000 and 2009, pharmaceutical spending increased on average in EU member states by 3.2% per year in real terms (slightly below the growth rate in total health spending), but the average growth in pharmaceutical spending in 2010 came to a halt (0.0%). In Ireland, pharmaceutical spending per capita increased at a rate of over 8% per year in real terms on average

126

between 2000 and 2009, but the growth rate slowed down markedly to less than 2% in 2010. This slowdown followed the introduction of a series of measures to control pharmaceutical spending in Ireland, including large price reductions and increases in co-payments by households. Several other countries severely affected by the economic crisis cut their spending on pharmaceuticals drastically in 2010: Iceland (–6.3%), Lithuania (–4.6%) and Portugal (–3.3%). Many European countries have attempted to control pharmaceutical expenditures even before the recession via a mix of price and volume controls directed at physicians and pharmacies, as well as policies targeting specific products (OECD, 2010b). In Germany, pharmaceutical companies must now enter into rebate negotiations with health insurance funds for new innovative medicines, putting an end to the previous free-pricing regime. Spain mandated a price reduction for generics and introduced a general rebate applicable for all medicines prescribed by NHS physicians in 2010. In France, price reductions or rebates on pharmaceuticals have often been used as adjustment variables to contain health spending growth while in the United Kingdom caps were introduced on pharmaceutical companies’ profits relating to NHS sales.

Definition and comparability Pharmaceutical expenditure covers spending on prescription medicines and self-medication, often referred to as over-the-counter products. In some countries, the data also include other medical non-durable goods (adding approximately 5% to the spending). The expenditure also includes pharmacists’ remuneration when the latter is separate from the price of medicines. Pharmaceuticals consumed in hospitals are excluded (their inclusion would add another 15% to pharmaceutical spending approximately). Final expenditure on pharmaceuticals includes wholesale and retail margins and value-added tax.

5.5. PHARMACEUTICAL EXPENDITURE

5.5.1. Expenditure on pharmaceuticals per capita and as a share of GDP, 2010 (or nearest year) Prescribed

Over-the-counter

Public

Total (no breakdown)

Pharmaceutical expenditure per capita

Pharmaceutical expenditure as a share of GDP Ireland1 Germany Belgium France Slovak Republic1 Hungary1 Spain Austria Italy1 Portugal1 Netherlands1 EU25 Sweden Finland Slovenia Cyprus Luxembourg1 Bulgaria 2 United Kingdom1 Czech Republic Lithuania1 Poland Denmark Estonia Latvia Romania1

528 492 479 468 427 414 399 396 393 391 370 349 343 340 336 322 317 291 289 274 257 237 229 210 175 164

1.7 1.7 1.7 1.9 2.4 2.6 1.8 1.3 1.6 2.0 1.1 1.6 1.2 1.2 1.8 1.3 0.6 2.8 1.0 1.5 1.9 1.6 0.8 1.4 1.5 1.4

Switzerland Iceland Norway1 Serbia 2

393 327 305 279

600 EUR PPP

400

Private

200

1.1 1.5 0.7 3.3

4 % GDP

1. Includes medical non-durables. 2. Total medical goods. Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932705577

5.5.2. Average annual growth in pharmaceutical expenditure per capita, in real terms, 2000 to 2010 (or nearest year) 2000-09

2009-10

2.5

2.3

1.2

2.2

1.8

1.9

2.1

3.1

3.4 0.2

0.2

1.4

1.8

2.4

3.2

3.4 2.4 1.3

1.3

1.5

2.3

3.1

3.8

4.1

4.6

5.7

9.3

7.9

8.6

-0.2 -3.1

-3.3

-6.3

-4.6

-5

-1.3

-0.1

0.0

-0.6

-1.0

-1.2

-1.3

-1.8

-1.4

ay rw

nd la er

it z

el Sw

d an

an m Ro

ic bl pu

Re ak

y an

rm Ge

s nd la er

th Ne

Ir e

ed Sw

an Fr

nd la

n ai

k ar nm

ly It a

lg Be

ria

d an

st Au

bl pu

r tu

l ga

a ua

ni Po

th Li

-10

Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932705596

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

127

5.6. FINANCING OF HEALTH CARE

All European countries use a mix of public and private financing to pay for health care. In some countries, public purchasing of health care is generally confined to the use of government revenues. In others where there is social insurance, public financing uses these social contributions, in addition to any general government revenues. Private financing of health care consists of payments by households (either as stand-alone payments or co-payments) as well as various forms of private health insurance intended to replace, complement or supplement publicly financed coverage. In addition, occupational health care may be directly provided by employers, and other health care benefits may be provided by charities and other non-government organisations. The public sector is the main source of health care financing in all European countries, except Cyprus (Figure 5.6.1). In 2010, on average in the European Union, 73% of health care was publicly financed. Public financing accounted for over 80% in the Netherlands, the Nordic countries (except Finland), Luxembourg, the Czech Republic, the United Kingdom and Romania. The share was the lowest in Cyprus (43%), and Bulgaria, Greece and Latvia (55-60%). The economic crisis has had an effect on the mix of public and private health financing as public spending has been contained or cut in many countries severely affected by the recession. In Ireland, the share of public spending decreased by nearly 6 percentage points between 2008 and 2010 and stands now at 70%. Substantial falls have also been observed in the Slovak Republic and Bulgaria. On the other hand, some countries saw their public spending share rise since 2008, including Cyprus and Norway. Although public funding is the main source of funds for health spending in nearly all European countries, this does not imply that the public sector plays the dominant financing role for all health services and goods. Figure 5.6.2 shows the shares of financing for medical services and medical goods separately. On average across the European Union, the public sector covers a much higher proportion of the costs of medical services compared with medical goods (comprising mainly pharmaceutical products). Over 80% of the costs of health care services are covered by public funds compared with just over 50% for medical goods. In Romania, public funding covers more than 90% of expenditure on medical services, but only about 40% of spending on medical goods. Germany, Luxembourg and the Netherlands are the only countries where public spending coverage for medical goods exceeds 70%. After public financing, the main source of funding for health expenditure is out-of-pocket payments. In 2010, the share of out-of-pocket payments was highest in Cyprus, Bulgaria and Greece. It was the lowest in the Netherlands (6%), France (7%) and the United Kingdom (9%). The share of out-of-pocket spending has increased over the past decade in about half of EU member states while it has decreased in

128

the other half. The Slovak Republic has seen the biggest increase in the share of health spending paid directly by households, with a rise of over 15 percentage points between 2000 and 2010. This increase is due to a rise in co-payments on prescribed pharmaceuticals, higher spending by households on non-prescribed medicines, increased use of private providers and informal payments to public providers (Szalay et al., 2011). The share of out-of-pocket payments has also increased substantially in Bulgaria, Cyprus and Malta. In some countries hard hit by the economic crisis, the public coverage for certain services has been reduced in recent years, with a growing share of payments being transferred to households. In Iceland, the share of out-of-pocket spending has increased by 2.2 percentage points between 2008 and 2010, although this has not totally offset the previous reduction in this share between 2000 and 2008. In Ireland, the share of out-of-pocket spending increased by 1.7 percentage points between 2008 and 2010, and is now 2.1 percentage points greater than in 2000. On the other hand, some other countries have extended public coverage for health services in recent years to improve access to care, resulting in a lower share of health spending paid directly by households. Turkey is the most striking example; it has moved since 2003 to extend public coverage for health services for a larger proportion of the population (see Indicator 5.1), with public funding now accounting for 73% of total health spending, equal to the EU average. This has led to a reduction of nearly 10 percentage points in the share of direct payments by households over the past decade. The share of out-of-pocket payments has also come down substantially in Poland and Switzerland, although it still remains slightly above the EU average.

Definition and comparability There are three elements of health care financing: sources of funding (households, employers and the state), financing schemes (e.g. compulsory or voluntary insurance), and financing agents (organisations managing financing schemes). Here “financing” is used in the sense of financing schemes as defined in the System of Health Accounts (OECD, 2000; OECD, Eurostat and WHO, 2011). Public financing includes general government revenues and social security funds. Private financing covers households’ out-of-pocket payments, private health insurance and other private funds (NGOs and private corporations). Out-of-pocket payments are expenditures borne directly by the patient. They include cost-sharing and, in certain countries, estimations of informal payments to health care providers.

5.6. FINANCING OF HEALTH CARE

5.6.1. Expenditure on health by type of financing, 2010 (or nearest year) Public % of total expenditure on health 100 2 0 3

5 6

Private out-of-pocket

3 9

1 1

Private insurance

Other

18 19

32 26

60 50 40

80 73

55 43

20 10

er la n De ds 1 L u nm C z xem ar k ec bo U n h R ur g i te epu d K i blic ng do Sw m ed Ro e n m an ia It a l Es y to n Au ia st ria 1 Fr a Ge nc e rm Be any lg iu m1 Fi nl an d Sp Sl a in ov en ia EU Li 2 7 th ua n Po i a la n Ir e d la Po nd r tu ga l M a lt a Sl H ov un ak ga Re r y pu bl ic La tv i Gr a ee Bu c e lg ar C y ia pr us

rw a Cr y oa t Ic i a el an T d M ur k on ey 1 te F Y Sw neg R it ze ro of r M lan ac d 1 ed on i Se a rb ia

1. Data refer to current expenditure. Source: OECD Health Data 2012; WHO Global Health Expenditure Database.

1 2 http://dx.doi.org/10.1787/888932705615

5.6.2. Public share of expenditure on medical services and goods, 2010 (or nearest year) Medical services Romania Czech Republic Netherlands Estonia Denmark Italy Sweden Lithuania France Poland Luxembourg Finland Austria EU23 Slovenia Germany Belgium Spain Bulgaria Slovak Republic Hungary Portugal Latvia Cyprus

Medical goods 92.6

39.8

91.5

59.8

90.5

71.0

88.6

50.2

88.6

51.6

87.2

48.4

87.0

54.0

86.8

35.6

85.2

61.2

83.8

39.8

83.0 77.5 81.7

45.6

81.0

61.9

80.5

51.5

80.5

49.9 70.2

77.0

63.9

77.0

64.1

76.4

20.5

74.8

59.0

74.4

48.3 55.4

71.2 69.2

33.6 45.1

22.1

Norway Iceland Serbia Switzerland

79.1

89.1

57.6

86.9

48.8 77.9

31.7

65.1 66.9

75 100 % total expenditure on function

Source: OECD Health Data 2012; Eurostat Statistics Database. 1 2 http://dx.doi.org/10.1787/888932705634

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

5.6.3. Change in share of out-of-pocket spending in total health spending, 2000 to 2010 (or nearest year) Slovak Republic Bulgaria Cyprus Malta Czech Republic Romania Ireland Germany Portugal Slovenia Greece EU27 Sweden France Hungary Luxembourg Belgium1 Austria1 Estonia Denmark United Kingdom Finland Netherlands1 Spain Latvia Lithuania Italy Poland

15.3 6.4 5.9 5.6 5.2 4.4 2.1 1.7 1.7 1.1 0.6 0.3 0.2 0.2 -0.1 -0.2 -0.6 -1.0 -1.4 -1.5 -2.5 -3.1 -3.9 -3.9 -4.4 -4.7 -6.7 -7.9

Serbia Montenegro Croatia Iceland Norway FYR of Macedonia Switzerland1 Turkey1

11.2 1.7 0.7 -0.8 -1.7 -6.2 -7.8 -9.7

-15

-10

-5

10 15 20 Percentage points

1. Data refer to current expenditure. Source: OECD Health Data 2012; WHO Global Health Expenditure Database. 1 2 http://dx.doi.org/10.1787/888932705653

129

5.7. TRADE IN HEALTH SERVICES

Trade in health services and its most high-profile component, medical tourism, has attracted a great deal of media attention in recent years. The growth in “imports” and “exports” has been fuelled by a number of factors. Technological advances in information systems and communication allow patients or third party purchasers of health care to seek out quality treatment at lower cost and/or more immediately from health care providers in other countries. An increase in the portability of health cover, whether as a result of regional arrangements with regard to public health insurance systems, or developments in the private insurance market, are also poised to further increase patient mobility. All this is coupled with a general increase in the temporary movement of populations for business, leisure or specifically for medical purposes between countries. While the major part of international trade in health services does involve the physical movement of patients across borders to receive treatment, to get a full measure of imports and exports, there is also a need to consider goods and services delivered remotely such as pharmaceuticals ordered from another country or diagnostic services provided from a doctor in one country to a patient in another. The magnitude of such trade remains small, but advances in technology mean that this area also has the potential to grow rapidly. Data on imports of health services and goods are available for most European countries and amounted to more than EUR 3 billion in 2010. The vast majority of this trade is between European countries. However, due to data gaps and under-reporting, this is likely to be a significant underestimate. With health-related imports reaching nearly EUR 1 500 million, Germany is by far the greatest importer in absolute terms, followed by the Netherlands and France. Nevertheless, in comparison to the size of the health sector as a whole, trade in health goods and services remains marginal for most countries. Even in the case of Germany, reported imports represent only around 0.5% of Germany’s health expenditure. The share rises above 1% of health spending only in Cyprus and Iceland, as these smaller countries see a higher level of cross-border movement of patients. Luxembourg is a particular case because a large part of its insured population is living and consuming health services in neighbouring countries. A smaller number of countries report total exports of health-related travel expenditure and other health services,

130

totalling around EUR 2.5 billion in 2010 (Figure 5.7.2). For many countries these figures are, again, likely to be significant underestimates. In absolute values, the Czech Republic and France reported exports in excess of EUR 400 million, while the exports of Turkey, Poland and the United Kingdom exceeded EUR 200 million. In relation to overall health spending, health-related exports remain marginal in most countries, except in the Czech Republic and Croatia where they equate to 4.2% and 2.8% of overall health spending. These countries have become popular destinations for patients from other European countries, particularly for services such as dental surgery. The growth rate in healthrelated exports has exceeded 20% per year over the past five years in the Czech Republic. Patient mobility in Europe may see further growth as a result of an EU directive adopted in 2011 which supports patients in exercising their right to cross border health care and promotes co-operation between health systems (Directive 2011/24/EU).

Definition and comparability The System of Health Accounts includes imports within current health expenditure, defined as imports of medical goods and services for final consumption. Of these the purchase of medical services and goods, by resident patients while abroad, is currently the most important in value terms. In the balance of payments, trade refers to goods and services transactions between residents and non-residents of an economy. According to the Manual on Statistics of International Trade in Services, “Health-related travel” is defined as “goods and services acquired by travellers going abroad for medical reasons”. This category has some limitations in that it covers only those persons travelling for the specific purpose of receiving medical care, and does not include those who happen to require medical services when abroad. The additional item “Health services” covers those services delivered across borders but can include medical services delivered between providers as well as to patients.

5.7. TRADE IN HEALTH SERVICES

5.7.1. Imports of health care services as share of total health expenditure, 2010 and annual growth rate in real terms, 2005-10 (or nearest year) Annual growth rate in real terms, 2005-10

2010 Luxembourg Cyprus1 Portugal Netherlands Bulgaria1 Belgium1 Germany Hungary Latvia Austria Slovak Republic Slovenia France 1 Italy1 Czech Republic Sweden Lithuania Estonia Denmark United Kingdom1 Poland Greece 1 Ireland1 Romania

8.60 || 2.47 0.91 0.81 0.81 0.60 0.52 0.30 0.29 0.28 0.22 0.21 0.19 0.17 0.15 0.13 0.12 0.11 0.08 0.08 0.07 0.06 0.06 0.04

0.60 0.40 0.14

7.4 3.1 -2.7 29.8 -11.3 9.3 17.7 -6.3 24.2 31.1 13.5 1.2 17.9 1.8 11.1 || 62.7 -1.9 -3.4 7.9 4.9 -5.5 0.8 30.9

Iceland Croatia1 Turkey1 Norway

1.09

3 2 % of total health expenditure

-7.7

12.2 -0.5 5.3 -3.9

-20

40 Annual growth rate (%)

1. Refers to balance of payments concept of health-related travel and health services of personal, recreational and cultural services. Source: OECD Health Data 2012 and OECD-Eurostat Trade in Services Database.

1 2 http://dx.doi.org/10.1787/888932705672

5.7.2. Exports of health-related travel or other services as share of total health expenditure, 2010 and annual growth rate in real terms, 2005-10 (or nearest year) Annual growth rate in real terms, 2005-10

2010 Czech Republic Luxembourg Hungary Slovenia Poland Estonia Belgium Cyprus Latvia Bulgaria Lithuania Austria France Sweden United Kingdom Greece Italy Romania Slovak Republic

4.17 1.38 1.19 1.00 0.93 0.87 0.77 0.72 0.70 0.58 0.46 0.36 0.18 0.17 0.13 0.13 0.12 0.11 0.08

0.88

24.8 -14.5 16.9 9.5 9.5 -17.5 -8.4 22.7 12.9 4.0 6.4 -3.6 -22.4 || 12.7 -12.1 -0.1 -3.8 -13.4

Croatia Turkey

2.75

6 4 % of total health expenditure

21.3

2.7 -6.8

-20

40 Annual growth rate (%)

Note: Health-related exports occur when domestic providers supply medical services to non-residents. Source: OECD-Eurostat Trade in Services Database.

1 2 http://dx.doi.org/10.1787/888932705691

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142

ANNEX A

Additional information on demographic and economic context Table A.1. Total population, mid-year, thousands, 1960 to 2010

Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany1 Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovak Republic Slovenia Spain Sweden United Kingdom EU Croatia FYR of Macedonia Iceland Montenegro Norway Serbia Switzerland Turkey

1960

1970

1980

1990

2000

2010

7 048 9 154 7 867 573 9 607 4 580 1 216 4 430 45 684 55 608 8 322 9 984 2 829 50 200 2 121 2 779 314 327 11 487 29 561 8 858 18 407 4 068 1 580 30 455 7 485 52 350

7 467 9 656 8 490 615 9 856 4 929 1 361 4 606 50 772 61 098 8 793 10 338 2 957 53 822 2 359 3 140 339 303 13 039 32 526 8 680 20 250 4 538 1 670 33 815 8 043 55 663

7 549 9 859 8 862 509 10 303 5 123 1 477 4 780 53 880 61 549 9 643 10 711 3 411 56 434 2 512 3 413 364 317 14 150 35 578 9 766 22 207 4 980 1 832 37 439 8 311 56 314

7 678 9 967 8 718 580 10 333 5 141 1 569 4 986 56 709 62 679 | 10 157 10 374 3 514 56 719 2 663 3 698 382 354 14 952 38 111 9 983 23 202 5 299 1 998 38 850 8 559 57 248

8 012 10 251 8 170 694 10 272 5 340 1 369 5 176 59 062 82 212 10 918 10 211 3 804 56 942 2 373 3 500 436 386 15 926 38 454 10 226 22 443 5 389 1 989 40 263 8 872 58 893

8 390 10 896 7 534 804 10 520 5 548 1 340 5 363 62 959 81 777 11 308 10 000 4 475 60 483 2 239 3 287 507 416 16 615 38 184 10 637 21 438 5 430 2 049 46 071 9 378 62 231

386 892

419 123

441 271

454 423

481 581

499 879

4 140 1 392 176 .. 3 581 .. 5 328 27 438

4 412 1 629 204 .. 3 876 .. 6 181 35 294

4 600 1 891 228 .. 4 086 .. 6 319 44 522

4 777 1 882 255 .. 4 242 .. 6 712 56 104

4 468 2 026 281 614 4 491 7 516 7 184 67 393

4 419 2 055 318 617 4 889 7 291 7 822 73 142

| Break in series. 1. Population figures for Germany prior to 1991 refer to West Germany. Source: OECD Health Data 2012; Eurostat Statistics Database.

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143

ANNEX A

Table A.2. Share of the population aged 65 and over, mid-year, 1960 to 2010 1960

1970

1980

1990

2000

2010

Austria

12.2

14.1

15.4

14.9

15.4

17.6

Belgium

12.0

13.4

14.3

14.9

16.8

17.2

Bulgaria

7.5

9.6

11.9

13.2

16.3

17.6

Cyprus1

10.8

10.9

11.3

13.0

9.5

12.0

13.4

12.5

13.8

15.4

Denmark

10.6

12.3

14.4

15.6

14.8

16.6

Estonia

10.5

11.7

12.5

11.6

15.1

17.0

Finland

7.3

9.2

12.0

13.4

14.9

17.3

France

11.6

12.9

13.9

14.0

16.1

16.9

Germany2

10.8

13.1

15.5

15.5 |

16.4

20.6

Greece

8.2

11.1

13.1

13.7

16.6

19.1

Hungary

9.0

11.6

13.4

13.3

15.1

16.7

11.1

10.7

11.4

11.2

11.5

9.3

10.9

13.1

14.9

18.3

20.3

Latvia

12.0

12.9

11.8

15.0

17.4

Lithuania

10.0

11.2

10.9

13.9

16.3

10.9

12.5

13.6

13.4

14.1

13.9

8.3

10.4

12.2

15.2

Netherlands

9.0

10.2

11.5

12.8

13.6

15.4

Poland

5.8

8.2

10.1

12.2

13.5

Portugal

7.9

9.4

11.3

13.4

16.2

18.0

Romania

8.6

10.3

10.4

13.3

14.9

Slovak Republic

6.9

9.1

10.5

10.3

11.4

12.3

Slovenia

7.8

9.9

11.4

10.7

14.0

16.5

Spain

8.2

9.6

11.0

13.6

16.8

17.0

Sweden

11.8

13.7

16.3

17.8

17.3

18.3

United Kingdom

11.7

13.0

14.9

15.7

15.8

16.5

12.5

13.0

14.7

16.4

16.0

17.1

10.0

11.7

8.1

8.8

9.9

10.6

11.6

12.1

11.9

12.7

11.0

12.9

14.8

16.3

15.2

15.0

16.1

16.9

10.2

11.4

13.8

14.6

15.3

17.5

3.6

4.4

4.7

4.4

5.4

7.1

Czech Republic

Ireland Italy

Luxembourg Malta

EU Croatia

FYR of Macedonia Iceland Montenegro4 Norway Serbia Switzerland Turkey

| Break in series. 1. Data for Cyprus in 1980 refers to 1982. 2. Population figures for Germany prior to 1991 refer to West Germany. 3. Data for Croatia in 2000 refers to 2002. 4. Data for Montenegro in 2000 refers to 2003. Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932705729

144

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

ANNEX A

Table A.3. Crude birth rate, per 1 000 population, 1960 to 2010 1960

1970

1980

1990

Austria

17.9

15.0

12.0

11.8

9.8

9.4

Belgium

16.8

14.7

12.6

12.4

11.4

11.9

Bulgaria

17.8

16.3

14.5

12.1

9.0

10.0

Cyprus1

26.2

19.2

20.4

18.3

12.2

11.8

Czech Republic

13.4

15.0

14.9

12.6

8.8

11.1

Denmark

16.6

14.4

11.2

12.3

12.6

11.4

Estonia

16.6

15.8

15.0

14.2

9.5

11.8

Finland

18.5

14.0

13.2

13.1

11.0

11.4

France

17.9

16.7

14.9

13.4

13.1

12.7

Germany2

17.4

13.3

10.1

11.5 |

9.3

8.3

Greece

18.9

16.5

15.4

10.1

9.5

10.1

Hungary

14.7

13.9

12.1

9.6

9.0

Ireland

21.5

21.8

21.7

15.1

14.4

16.5

Italy

18.1

16.7

11.3

10.0

9.5

9.3

Latvia

16.7

14.6

14.1

14.2

8.5

8.6

Lithuania

22.5

17.7

15.2

15.4

9.8

10.8

Luxembourg

16.0

13.0

11.4

12.9

13.1

11.6

Malta

26.2

17.6

17.7

15.2

11.5

9.6

Netherlands

20.8

18.3

12.8

13.2

13.0

11.1

Poland

22.6

16.8

19.6

14.4

9.8

10.8

Portugal

24.1

20.8

16.2

11.7

9.5

Romania

19.1

21.1

17.9

13.6

10.4

9.9

Slovak Republic

21.7

17.8

19.1

15.1

10.2

11.1

Slovenia

17.6

15.9

15.7

11.2

9.1

10.9

Spain

21.7

19.5

15.3

10.3

9.9

10.5

Sweden

13.7

11.7

14.5

10.2

12.3

United Kingdom

17.5

16.2

13.4

13.9

11.5

13.0

19.0

16.6

14.9

13.1

10.7

10.9

Croatia

18.4

13.8

14.8

11.6

9.8

FYR of Macedonia

31.7

23.2

21.0

18.8

14.5

11.8

Iceland

28.0

19.7

19.8

18.7

15.3

15.4

15.0

12.0

17.3

16.7

12.5

14.4

13.2

12.6

9.8

9.4

17.7

16.1

11.7

12.5

10.9

10.3

20.2

16.9

Montenegro Norway Serbia Switzerland Turkey

2000

2010

| Break in series. 1. Data for Cyprus in 1960 refers to 1961. 2. Population figures for Germany prior to 1991 refer to West Germany. Source: Eurostat Statistics Database.

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145

ANNEX A

Table A.4. Fertility rate, number of children per women aged 15-49, 1960 to 2010 1960

1970

1980

1990

2000

2010

Austria

2.7

2.3

1.7

1.5

1.4

Belgium

2.5

2.3

1.7

1.6

1.7

1.9

Bulgaria

2.3

2.2

2.1

1.8

1.3

1.5

Cyprus1

2.5

2.4

1.6

1.5

Czech Republic

2.1

1.9

2.1

1.9

1.1

1.5

Denmark

2.5

2.0

1.5

1.7

1.8

1.9

Estonia

2.0

1.4

1.6

Finland

2.7

1.8

1.6

1.8

1.7

1.9

France

2.7

2.5

1.9

1.8

1.9

2.0

Germany

2.4

2.0

1.6

1.5

1.4

Greece

2.2

2.4

2.2

1.4

1.3

1.5

Hungary

2.0

1.9

1.8

1.3

Ireland

3.8

3.9

3.2

2.1

1.9

2.1

Italy

2.4

1.7

1.4

1.3

1.4

Latvia2

1.2

Lithuania

2.4

2.0

1.4

1.6

2.3

2.0

1.5

1.6

1.8

1.6

2.0

1.7

1.4

Netherlands

3.1

2.6

1.6

1.7

1.8

Poland

3.0

2.2

2.3

2.0

1.4

Portugal

3.1

2.8

2.2

1.6

1.4

Romania3

2.4

1.8

1.3

1.4

Slovak Republic

3.1

2.4

2.3

2.1

1.3

1.4

Slovenia

2.2

2.1

1.5

1.3

1.6

Spain

2.9

2.2

1.4

1.2

1.4

Sweden

2.2

1.9

1.7

2.1

1.5

2.0

United Kingdom

2.7

2.4

1.9

1.8

1.6

2.0

1.8

1.5

1.6

1.3

1.5

1.9

1.6

4.3

2.8

2.5

2.3

2.1

2.2

1.7

Norway

2.9

2.5

1.7

1.9

2.0

Serbia

1.5

1.4

Switzerland

2.4

2.1

1.6

1.5

Turkey

6.4

5.0

4.6

3.1

2.3

2.0

Luxembourg Malta

EU Croatia

FYR of Macedonia Iceland Montenegro

1. Data for Cyprus in 1980 and 2010 refer to 1982 and 2009 respectively. 2. Data for Latvia and Croatia in 2000 refer to 2002. 3. Data for Romania in 2010 refers to 2009. Source: OECD Health Data 2012; Eurostat Statistics Database.

1 2 http://dx.doi.org/10.1787/888932705767

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ANNEX A

Table A.5. GDP per capita in 2010 and average annual growth rates, 1980 to 2010 GDP per capita in EUR PPP

Annual growth rate in real terms

2010

1980-90

1990-2000

2000-10

Austria

30 793

2.0

2.2

1.1

Belgium

28 943

1.9

0.8

Bulgaria

10 678

4.9

Cyprus

24 223

1.3

Czech Republic

19 431

0.5

3.1

Denmark

30 941

2.0

2.2

0.2

Estonia3

15 678

6.5

3.7

Finland

28 095

2.6

1.7

1.4

France

26 268

1.9

1.5

0.5

Germany2, 4

28 769

2.1

1.3

1.0

Greece

21 898

0.2

1.6

1.8

Hungary4

15 806

1.9

2.2

Ireland

31 147

3.3

6.0

0.7

Italy

24 561

2.4

1.6

-0.2

Latvia

12 469

4.3

Lithuania

13 848

4.9

Luxembourg

66 207

4.5

3.6

1.2

Malta

20 293

0.7

Netherlands

32 442

1.7

2.5

0.9

Poland

15 286

3.7

4.0

Portugal

19 549

3.0

2.7

0.2

Romania

11 353

4.6

Slovak Republic5

17 914

3.7

4.7

Slovenia

20 728

1.9

2.4

Spain

24 477

2.6

2.4

0.7

Sweden

30 287

1.9

1.7

1.5

United Kingdom

27 400

2.6

1.1

EU27 (unweighted)

24 055

2.0

EU27 (weighted)1

24 474

1.0

Croatia

14 505

2.7

8 872

2.4

Iceland

27 188

1.6

1.5

0.9

Montenegro

10 142

4.5

Norway

44 149

2.1

3.1

0.6

Serbia6

8 405

4.7

Switzerland

35 718

1.6

0.4

0.8

Turkey

11 970

2.8

1.8

3.0

FYR of Macedonia

1. The weighted average is calculated based on total GDP divided by the total population of the 27 EU member states. 2. Data prior to 1990 refers to Western Germany. 3. Data available from 1993. 4. Data available from 1991. 5. Data available from 1992. 6. Latest year 2009. Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Health Expenditure Database. 1 2 http://dx.doi.org/10.1787/888932705786

HEALTH AT A GLANCE: EUROPE 2012 ÂŠ OECD 2012

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ANNEX A

Table A.6. Total expenditure on health per capita in 2010, average annual growth rates, 2000 to 2010 Total health expenditure per capita in EUR PPP

Annual growth rate per capita in real terms1

2010

2006/07

2007/08

2008/09

2009/10

2000-10 (or latest year)

Austria

3 383

3.7

3.2

2.3

0.1

2.0

Belgium9

3 052

2.5

4.2

2.8

0.2

3.4

Bulgaria5

745

5.8

9.3

-1.7

4.1

Cyprus7

1 783

-0.3

16.4

4.4

-0.2

2.2

Czech Republic

1 450

2.4

6.8

11.1

-4.4

4.9

Denmark

3 439

1.8

0.6

5.3

-2.1

2.7

Estonia

995

10.7

12.7

-0.5

-7.3

5.6

Finland

2 504

1.1

3.1

0.7

0.4

3.6

France

3 058

1.5

-1.4

2.7

0.8

1.9

Germany

3 337

1.8

3.4

4.3

2.7

2.1

Greece

2 244

3.6

2.6

0.5

-6.7

4.4

Hungary

1 231

-6.8

-1.7

-3.2

2.2

3.0

Ireland

2 862

5.6

9.6

2.7

-7.9

5.0

Italy

2 282

-2.8

1.0

-1.6

1.0

1.3

Latvia6

821

13.6

-8.1

-14.8

2.7

Lithuania8

972

10.8

9.7

-2.2

-5.0

6.4

Luxembourg3

3 607

-4.9

-7.1

7.5

0.6

Malta

1 758

-3.3

-0.2

-0.8

3.6

3.5

Netherlands

3 890

3.2

3.6

2.0

5.2

Poland

1 068

9.1

14.3

6.4

0.5

6.4

Portugal

2 097

1.7

2.1

2.7

0.5

1.7

677

9.6

11.5

-3.0

4.2

5.4

Slovak Republic

1 614

16.5

9.2

8.2

2.4

10.0

Slovenia

1 869

1.0

9.2

1.9

-2.0

3.3

Spain

2 345

2.8

4.6

2.8

-0.9

3.6

Sweden

2 894

2.2

2.1

1.4

1.2

3.1

United Kingdom

2 636

3.0

1.5

6.3

-0.5

4.3

EU27 (unweighted)

2 171

3.6

4.5

1.9

-0.6

3.8

EU27 (weighted)2

2 470

1.7

2.3

3.4

0.4

2.8

Croatia

1 152

12.7

5.2

-5.9

-1.2

2.7

619

-7.2

3.9

-0.6

5.7

0.1

2 524

3.2

-0.9

-1.4

-7.1

0.7

899

0.4

8.1

11.7

5.9

Norway

4 156

2.7

2.6

1.6

-2.0

2.4

Serbia3

902

18.1

6.0

-1.3

8.9

4 056

1.2

2.0

2.9

1.4

1.9

714

10.2

0.0

6.4

Romania7

FYR of Macedonia Iceland Montenegro3

Switzerland Turkey4

1. Using national currency units at 2005 GDP price level. 2. The weighted average is calculated based on total health spending divided by the total population of the 27 EU member states. 3. Most recent year 2009. 4. Most recent year 2008. 5. Data for 2003-09. 6. Data for 2004-09. 7. Data since 2003. 8. Data since 2004. 9. Excluding investment. Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Health Expenditure Database. 1 2 http://dx.doi.org/10.1787/888932705805

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ANNEX A

Table A.7. Total expenditure on health, percentage of GDP, 1980 to 2010 1980

1990

2000

2005

2007

2008

2009

2010

Austria

7.4 |

8.4

10.0

10.4

10.3

10.5

11.2 |

11.0

Belgium2

6.3

7.2

8.1

10.1

9.6

10.0

10.7

10.5

Bulgaria

6.2

7.3

6.8

7.0

7.2

Cyprus

5.8

6.4

6.1

6.9

7.4

4.5 |

6.3 |

6.9

6.5

6.8

8.0

7.5

8.9

8.3

8.7 |

9.8

10.0

10.2

11.5

11.1

Czech Republic Denmark Estonia

5.3

5.0

5.2

6.0

7.0 |

Finland

6.3

7.7 |

7.2

8.4

8.0

8.3

9.2

8.9

France

7.0

8.4 |

10.1

11.2

11.1

11.0

11.7

11.6

Germany

8.4

8.3 |

10.4

10.8

10.5

10.7

11.7

11.6

Greece

5.9

6.7

8.0

9.7

9.8

10.1

10.6

10.2

7.1

7.2

8.4

7.7

7.5

7.7

7.8

8.2

6.0

6.1

7.6

7.8

8.9

9.9

9.2

Italy

7.7

8.0

8.9

8.6 |

8.9

9.3

Latvia

6.0

6.4

7.0

6.6

6.8

Lithuania

6.5

5.8

6.2

6.6

7.5

7.0

5.2

5.4 |

7.5

7.9

7.1

6.8

7.9

6.7

9.3

8.7

8.3

8.5

8.6

7.4

8.0 |

8.0

9.8 |

10.8

11.0

11.9

12.0

4.8

5.5 |

6.2

6.3

6.9

Portugal

5.1

5.7 |

9.3

10.4

10.0

10.2

10.8

10.7

Romania

5.2

5.5

5.2

5.4

5.6

6.0

Slovak Republic

5.5

7.0

7.8

8.0

9.2

9.0

Slovenia

8.3 |

8.3

7.8

8.3

9.3

9.0

Spain

5.3

6.5 |

7.2 |

8.3

8.5

8.9

9.6

Sweden

8.9

8.2 |

8.2

9.1

8.9

9.2

9.9

9.6

United Kingdom

5.6

5.9 |

7.0

8.2

8.5

8.8

9.8

9.6

7.3

8.3

8.2

8.4

9.2

9.04

8.6

9.5

9.4

9.6

10.4

10.3

Croatia

7.8

7.0

7.5

7.8

FYR of Macedonia

8.8

8.1

6.9

6.8

6.9

7.1

6.3

7.8

9.5

9.4

9.1

9.6

9.3

7.9

9.1

7.8

8.0

9.4

9.1

Norway

7.0

7.6 |

8.4 |

9.0

8.7

8.6

9.8

9.4

Serbia

7.4

9.1

10.4

10.5

10.4

Switzerland

7.4

8.2 |

10.2

11.2

10.6

10.7

11.4

Turkey

2.4

2.7 |

4.9

5.4

6.0

6.1

Hungary3 Ireland

Luxembourg Malta Netherlands Poland

EU27 (unweighted) EU27

(weighted)1

Iceland Montenegro

7.2 |

6.3

7.0

| Break in series. 1. The weighted average is calculated based on total health spending divided by total GDP across the 27 EU member states. 2. Excluding investment. 3. Data for 1990 refers to 1991. 4. The average is calculated on the most recent data available. Source: OECD Health Data 2012; Eurostat Statistics Database; WHO Global Health Expenditure Database. 1 2 http://dx.doi.org/10.1787/888932705824

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ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT The OECD is a unique forum where governments work together to address the economic, social and environmental challenges of globalisation. The OECD is also at the forefront of efforts to understand and to help governments respond to new developments and concerns, such as corporate governance, the information economy and the challenges of an ageing population. The Organisation provides a setting where governments can compare policy experiences, seek answers to common problems, identify good practice and work to co-ordinate domestic and international policies. The OECD member countries are: Australia, Austria, Belgium, Canada, Chile, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Korea, Luxembourg, Mexico, the Netherlands, New Zealand, Norway, Poland, Portugal, the Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Turkey, the United Kingdom and the United States. The European Union takes part in the work of the OECD. OECD Publishing disseminates widely the results of the Organisation’s statistics gathering and research on economic, social and environmental issues, as well as the conventions, guidelines and standards agreed by its members.

OECD PUBLISHING, 2, rue André-Pascal, 75775 PARIS CEDEX 16 (81 2012 12 1 P) ISBN 978-92-64-18360-5 – No. 60319 2012

Health at a Glance Europe 2012 This second edition of Health at a Glance: Europe presents a set of key indicators of health status, determinants of health, health care resources and activities, quality of care, health expenditure and financing in 35 European countries, including the 27 European Union member states, 5 candidate countries and 3 EFTA countries. The selection of indicators is based largely on the European Community Health Indicators (ECHI) shortlist, a set of indicators that has been developed to guide the reporting of health statistics in the European Union. It is complemented by additional indicators on health expenditure and quality of care, building on the OECD expertise in these areas. Each indicator is presented in a user-friendly format, consisting of charts illustrating variations across countries and over time, a brief descriptive analysis highlighting the major findings conveyed by the data, and a methodological box on the definition of the indicator and any limitations in data comparability. Contents Chapter 1. Health status Chapter 2. Determinants of health Chapter 3. Health care resources and activities Chapter 4. Quality of care Chapter 5. Health expenditure and financing

Please cite this publication as: OECD (2012), Health at a Glance: Europe 2012, OECD Publishing. http://dx.doi.org/10.1787/9789264183896-en This work is published on the OECD iLibrary, which gathers all OECD books, periodicals and statistical databases. Visit www.oecd-ilibrary.org, and do not hesitate to contact us for more information.

isbn 978-92-64-18360-5 81 2012 12 1 P

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CONTENIDO: 1 Panorama de la salud: Europa 2012 2

Se prohíbe la reproducción total o parcial del contenido de este "Boletín Europa al Día " sin citar la fuente o sin haber obtenido el permiso del Consejo General de Colegios Médicos de España. 2 Disponible en la página web del Consejo General de Colegios Médicos: http://www.cgcom.es 1

Panorama de la salud: Europa 2012 La Comisión Europea y la OCDE han publicado conjuntamente un informe que recoge los indicadores clave sobre los factores determinantes de la salud, los recursos y actividades de la asistencia sanitaria, la calidad de la atención sanitaria y el gasto y la financiación de la salud en 35 países europeos

En general, la situación sanitaria ha mejorado considerablemente aunque siguen existiendo grandes diferencias. El número de médicos y de enfermeros per cápita es más alto que nunca en la mayoría de los países, pero preocupa la escasez actual o futura de personal. La DG Salud y Consumidores de la Comisión Europea y la Organización de Cooperación y Desarrollo Económicos (OCDE) han publicado conjuntamente la segunda edición del informe "Panorama de la salud: Europa 2012". Este informe presenta una serie de indicadores clave sobre los factores determinantes de la salud, los recursos y actividades de la asistencia sanitaria, la calidad de la atención sanitaria y el gasto y la financiación de la salud en 35 países europeos, que son, los 27 Estados miembros de la UE, 5 países candidatos y 3 países de la AELC/EFTA. Hasta el año 2009, el gasto sanitario en Europa creció más deprisa que el resto de la economía, y el sector de la salud absorbió una creciente proporción del Producto Interior Bruto (PIB). Debido al estallido de la crisis económica y financiera en 2008, muchos países europeos redujeron el gasto en asistencia sanitaria como parte de un esfuerzo más amplio para controlar los graves déficits presupuestarios y los crecientes ratios deuda/PIB. Aunque esos recortes fueran posiblemente inevitables, algunas medidas pueden haber afectado los objetivos fundamentales de los sistemas sanitarios. Panorama de la salud: Europa 2012 presenta las tendencias a lo largo del tiempo y las variaciones en cuanto a cinco grandes temas: 1) estado de salud de la población; 2) factores de riesgo para la salud; 3) recursos y actividades de los sistemas de atención sanitaria; 4) calidad de la atención en caso de enfermedades crónicas y dolencias agudas; 5) gasto sanitario y fuentes de financiación.

Mejoras en la calidad de la atención sanitaria: • Se han registrado progresos en el tratamiento de las afecciones potencialmente mortales como el ataque al corazón, o el ictus y el cáncer, en todos los países europeos incluidos en el estudio. Los índices de mortalidad tras una hospitalización por un ataque al corazón (infarto agudo de miocardio) disminuyeron casi en un 50 % entre 2000 y 2009. y en más del 20 % en el caso del ictus. Estas mejoras se reflejan en la atención de las dolencias agudas y en un mayor acceso a las unidades exclusivamente destinadas al ictus en países como Dinamarca y Suecia. • También han mejorado los índices de supervivencia para distintos tipos de cáncer en casi todos los países, gracias a una detección precoz y a una mejor eficacia de los tratamientos. Los índices de supervivencia en el caso del cáncer de mama siguen siendo inferiores al 80 % en Chequia y Eslovenia, pero aumentaron en más de diez puntos porcentuales entre 19972002 y 2004-2009. Estos dos países también han experimentado una notable mejoría en sus índices de supervivencia relativos al cáncer colorrectal.

Gasto sanitario: • El aumento del gasto sanitario per cápita se ralentizó o incluso se detuvo en términos reales en 2010 en casi todos los países europeos, lo que invirtió una tendencia de incremento constante. El gasto ya había comenzado a reducirse en 2009 en los países que se habían visto más afectados por la crisis económica (por ej. Estonia e Islandia), pero a continuación, en 2010 se produjeron recortes más profundos en respuesta a las sucesivas presiones presupuestarias y a los crecientes ratios deuda/PIB. En la UE, el gasto sanitario per cápita aumentó como término medio en un 4,6 % anual en términos reales entre 2000 y 2009, y descendió a continuación un 0,6 % en 2010.

Recortes del gasto público en el ámbito sanitario: • Los recortes del gasto público en el ámbito sanitario se llevaron a cabo a través de una serie de medidas, que incluyen reducciones de salarios y/o de nivel de empleo, lo cual provoca un aumento de los pagos directos de los hogares para determinados servicios y productos farmacéuticos e impone rigurosas restricciones presupuestarias a los hospitales. También se han llevado a cabo fusiones de hospitales y acelerado la transición de la hospitalización a la asistencia y la cirugía ambulatorias. • Como consecuencia del crecimiento negativo del gasto sanitario en 2010, el porcentaje del PIB destinado a asistencia sanitaria se estabilizó o disminuyó ligeramente en numerosos Estados miembros de la UE, que en 2010, destinaron una media del 9,0 % (no ponderada) de su PIB a la asistencia sanitaria, lo que significa una importante subida en relación con el 7,3 % de 2000, pero es ligeramente inferior al máximo del 9,2 % alcanzado en 2009.

• Holanda fue el país que destinó el mayor porcentaje del PIB a sanidad en 2010 (12%), seguido de Francia y Alemania (ambas el 11,6%). En términos de gasto en asistencia sanitaria per cápita, los Países Bajos (3.890 EUR), Luxemburgo (3.607 EUR) y Dinamarca (3.439 EUR) fueron los Estados miembros de la UE que más gastaron. Les siguen Austria, Francia y Alemania, con más de 3.000 EUR per cápita. Bulgaria y Rumanía fueron los países que menos gastaron, en torno a 700 EUR. • El sector público es la principal fuente de financiación de la asistencia sanitaria en todos los países europeos excepto en Chipre. En 2010, casi tres cuartas partes (73%) de todo el gasto en sanidad, como media, se financiaron con fondos públicos en los Estados miembros de la UE. En los Países Bajos, los países nórdicos (excepto Finlandia), Luxemburgo, Chequia, el Reino Unido y Rumanía, más del 80% del gasto se financió con fondos públicos. El porcentaje más bajo se registró en Chipre (43%) y en Bulgaria, Grecia y Letonia (55-60%). • En algunos países, la crisis económica ha afectado al equilibrio entre la financiación pública y privada de la asistencia sanitaria. Se ha recortado el gasto público en

determinados bienes y servicios, a veces en combinación con aumentos en el porcentaje de los pagos directos para los hogares. En Irlanda, el porcentaje de la financiación pública del gasto sanitario disminuyó en casi seis puntos porcentuales entre 2008 y 2010, y se sitúa actualmente en el 70%, mientras que aumentó el porcentaje de los pagos directos realizados por los hogares. También ha habido descensos significativos en Bulgaria y Eslovaquia. • Tras la financiación pública, la fuente principal de financiación del gasto sanitario en la mayoría de los países son los pagos directos. La financiación mediante un seguro médico privado solo juega un papel importante en unos pocos países. En 2010, el porcentaje de pagos directos más elevado se dio en Chipre (49%), Bulgaria (43%) y Grecia (38%). El más bajo lo registraron los Países Bajos (6%), Francia (7%) y el Reino Unido (9%). Este porcentaje aumentó durante la última década en casi la mitad de los Estados miembros de la UE, sobre todo en Bulgaria, Chipre, Malta y Eslovaquia.

Número de médicos: • Garantizar un acceso adecuado a la asistencia sanitaria es un objetivo político fundamental en todos los Estados miembros de la UE que requiere, entre otras cosas, disponer del número adecuado de profesionales de la salud distribuido de manera que responda a las necesidades de la población. En muchos países europeos preocupa la falta de médicos y de enfermeros, a pesar de que los recientes recortes del gasto público en el ámbito sanitario en algunos países puedan haber dado lugar a una reducción al menos temporal de la demanda. Desde 2000, el número de médicos per cápita ha aumentado en casi todos los Estados miembros de la UE que, como término medio, pasó de 2,9 médicos por mil habitantes en 2000 a 3,4 en 2010. El aumento fue especialmente rápido en Grecia y el Reino Unido.

Médicos generalistas y especialistas: • En casi todos los países, el equilibrio entre médicos generalistas y especialistas ha cambiado, de manera que ahora hay más especialistas. La explicación puede ser un menor interés por la práctica de la «medicina de cabecera» tradicional, junto con una creciente diferencia salarial entre generalistas y especialistas. El crecimiento lento o la reducción del número de médicos generalistas afecta en muchos países a la atención primaria para determinados grupos de población.

Enfermedades crónicas: • Se observa un aumento de enfermedades crónicas, como la diabetes, el asma y la demencia, debido a un mejor diagnóstico o a que esas dolencias están aumentando realmente. Más de un 6% de personas de edades comprendidas entre 20 y 79 años en la Unión Europea, lo que equivale a 30 millones de personas, tenían diabetes en 2011. Gestionar mejor las enfermedades crónicas se ha convertido en una prioridad de política sanitaria para numerosos Estados miembros de la UE.

Tabaquismo: • La mayor parte de los países europeos han reducido el consumo de tabaco mediante campañas de sensibilización de la opinión pública, la prohibición de la publicidad y mayores impuestos. El porcentaje de adultos que fuman a diario está por debajo del 15% en Suecia e Islandia, frente al 30% registrado en 1980. En el otro extremo, más de un 30% de adultos fuman diariamente en Grecia. El índice de tabaquismo sigue siendo elevado en Bulgaria, Irlanda y Letonia. 2.5.1. Población activa que fuma diariamente y cambios en la tasa de fumadores de 2000-2010

Alcohol: • Ha descendido el consumo de alcohol en muchos países europeos. Se ha demostrado que las restricciones de la publicidad y venta y el aumento de los impuestos son medidas eficaces. En países vitícolas tradicionales, como España, Francia e Italia, el consumo per cápita ha descendido mucho desde 1980. El consumo de alcohol por adulto aumentó considerablemente en Chipre, Finlandia e Irlanda.

2.6.1. Consumo de alcohol entre la población de 15 y más años y cambios 1980-2010.

Sobrepeso: • En la Unión Europea, el 52% de la población adulta tiene sobrepeso, el 17% de la cual es obesa. A nivel nacional, la frecuencia del sobrepeso y la obesidad supera el 50% en dieciocho de los veintisiete Estados miembros de la UE. Los índices son mucho más bajos en Francia, Italia y Suiza, aunque también están subiendo en estos países. La frecuencia de la obesidad, que supone un riesgo mayor para la salud que el sobrepeso, va de menos de un 8% en Rumanía y Suiza a más de un 25% en Hungría y el Reino Unido. El índice de obesidad se ha duplicado desde 1990 en muchos países europeos. El aumento de la obesidad ha afectado a todos los grupos de población, en distintos grados, aunque tiende a ser más común entre los grupos sociales desfavorecidos y especialmente entre las mujeres. 2.7.2. Aumento de la obesidad entre los adultos Europeos, 1990, 2000, 2010

Esperanza de vida: • La esperanza de vida al nacer en los Estados miembros de la UE aumentó en seis años desde 1980 y 2010. Francia tiene la esperanza de vida más alta para las mujeres (85 años) y Suecia para los hombres (79,4 años). Bulgaria y Rumanía tienen la esperanza de vida al nacer más baja de la UE para las mujeres (77,3 años) y Lituania para los hombres (67,3 años). La diferencia entre Estados miembros de la UE con las esperanzas de vida al nacer más altas y bajas se encuentra en torno a ocho años para las mujeres y doce para los hombres.

Personal de enfermería: • También preocupa la posible escasez de personal de enfermería, lo cual puede intensificarse en el futuro ya que la demanda de enfermeros sigue aumentando y el envejecimiento de la generación del baby boom provoca una oleada de jubilaciones en esa profesión. En la última década, el número de enfermeros per cápita aumentó en casi todos los Estados miembros de la UE. El aumento fue especialmente elevado en Dinamarca, Francia, Portugal y España. Sin embargo, recientemente ha habido una reducción de los enfermeros contratados en determinados países que se han visto más afectados por la crisis económica. En Estonia, el número de enfermeros aumentó hasta 2008, pero después disminuyó, pasando de 6,4 por mil habitantes en 2008 a 6,1 en 2010. Entre las principales conclusiones del informe, pueden señalarse las siguientes: •

La esperanza de vida al nacer en los países de la UE aumentó en más de seis años entre 1980 y 2010.

•

La prevalencia de enfermedades crónicas como la diabetes, el asma y la demencia es cada vez más elevada.

•

La mayor parte de los países europeos ha reducido el consumo de tabaco mediante campañas de sensibilización de la opinión pública, la prohibición de la publicidad y mayores impuestos.

•

El aumento del gasto sanitario per cápita se ralentizó o incluso se detuvo en términos reales en 2010 en casi todos los países europeos, lo que invirtió una tendencia de incremento constante.

Incluimos, en el presente Boletín “Europa al día” el informe “panorama de la salud: Europa 2012”, del que sólo existe versión inglesa.

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CONCLUSIONES VIH 2012 (DOCUMENTO DE CONCLUISIONES: ESPAÑA VIH 2012. PLATAFORMA VIH EN ESPAÑA) ______________________________________________________________________

Las tasas de nuevos diagnósticos de VIH en España son similares a las de otros países en Europa Occidental, aunque superiores a la media del conjunto de la Unión Europea. El retraso en el diagnóstico es una asignatura pendiente y solo ha descendido entre los HSH. Por lo tanto, promover el diagnóstico precoz debe ser un factor clave para el control de la epidemia en Europa. Aún en un entorno de crisis económica, se deben potenciar los programas de prevención y diagnóstico precoz del VIH. Además, los últimos estudios de evaluación económica señalan el coste-eficacia de un diagnóstico precoz. Un punto clave a la hora de hablar del tratamiento es evaluar el beneficio coste-eficacia y conocer cual es la mejor manera de optimizar los recursos cuando estos son limitados. Según los datos presentados en la conferencia, la terapia antirretroviral es coste-efectiva y desde el año 1999 a 2004 su coste se ha reducido a menos de la mitad. En función de las características de la epidemia en cada país y de su sistema sanitario, se deben desarrollar estrategias concretas de promoción del diagnóstico precoz. Cada vez más, las ONGs están desarrollando una importante labor en materia de prevención, formación y diagnóstico precoz del VIH pro su capacidad de acercarse a la población joven, un segmento de la población de difícil acceso para el sistema sanitario.

Impacto positivo del diagnóstico precoz Actualmente existe consenso sobre el impacto positivo del diagnóstico precoz y cómo el tratamiento de las personas diagnosticadas supone una medida relevante para la prevención de nuevas infecciones, mientras que el infradiagnóstico tiene implicaciones negativas para la propagación de la epidemia y la evolución clínica de los propios afectados. En el encuentro celebrado en Madrid, los expertos han debatido sobre las medidas más adecuadas para llevar a cabo esta detección temprana que en España deberían enmarcarse dentro de la Ley de Salud Pública, aprobada en septiembre de 2011. En este sentido, e independientemente del método que se adopte, se considera indispensable la implicación de los gobiernos locales, nacionales y de las instituciones sanitarias europeas. El diagnóstico precoz pasa necesariamente por aumentar el número de pruebas que se realizan actualmente, con un cambio en los criterios que hoy se aplican para solicitarlas. Este es uno de los puntos clave donde las administraciones deben intervenir para facilitar la labor de los profesionales.

El acceso a la prueba y al tratamiento temprano, por tanto, es fundamental para la prevención, ya que sin diagnóstico no hay acceso al tratamiento y la transmisión de la infección es mayor. Así, la importancia de realizar el diagnóstico a tiempo reside en que cuanto más tarda en detectarse la infección, mayor es la morbilidad y la mortalidad. Por otra parte, tal y como señaló el Dr. Moreno en la clausura del encuentro, “no es cuestión de voluntarismo”, sino de adoptar “medidas a gran escala en las que estén implicadas las Administraciones sanitarias”. Infección por VIH Como resultado de los datos y opiniones expuestos durante la Reunión VIH 2012, los expertos destacan que en Europa existen entre 700.000-900.000 personas que están infectadas con el VIH y que aún no se han diagnosticado, lo que da lugar, por un lado, al inicio tardío del tratamiento, y por otro, a un incremento en el riesgo de transmisión a otras personas. El incremento de estos índices supone un problema desde la perspectiva de salud pública, cuyo objetivo es aumentar el porcentaje de personas con VIH que saben que están infectadas, sin olvidar que para conseguirlo el primer paso es disminuir el número de personas que se infectan. Desde el ámbito político y ejerciendo su papel de líderes a distintos niveles, también deben tomarse medidas tanto a nivel local como nacional e internacional. Comenzando por el Parlamento Europeo, donde se está intentando estandarizar medidas que consigan el diagnóstico precoz de las enfermedades, gracias a la cooperación entre las autoridades de los países miembros de la Unión y los países vecinos. A nivel nacional, se intenta dar respuesta al problema del sida, promoviendo programas de prevención, acceso al diagnóstico y tratamiento, brindando asesoramiento, y sin olvidar la educación social.

Barreras que dificultan el acceso a la prueba del VIH por parte de la población Entre las principales barreras que dificultan el acceso a la prueba se encuentran el desconocimiento, la falta de percepción del riesgo por parte del paciente y de los profesionales sanitarios y la posibilidad de que un positivo conlleve rechazo social. Desde el punto de vista de los profesionales sanitarios, es imprescindible mejorar sus habilidades clínicas sobre conductas de riesgo: prácticas sexuales y hábitos tóxicos. La sensibilización, formación e información del personal sanitario es necesaria para identificar marcadores clínicos y conductuales y promover el diagnóstico precoz, ya que los datos indican que el 90 por ciento de los pacientes diagnosticados había acudido al médico al menos una vez durante ese año. De hecho, la razón principal por la que los infectados se realizaron la prueba del VIH fue la recomendación del médico de Atención Primaria.

Otra de las barreras es el condicionante social, desde este punto de vista la normalización de la enfermedad es todavía una asignatura pendiente.

Avances en el tratamiento del VIH Los avances más significativos han sido el inicio de tratamiento antirretroviral en fases más precoces de la infección – cuando el paciente se encuentra mejor – y la incorporación a esquemas terapéuticos que proporcionan un tratamiento completo en un solo comprimido al día. Por otra parte, el establecimiento de que el tratamiento es una medida extraordinaria para prevenir la transmisión del VIH también ha modificado el abordaje en muchos casos, por lo que se debe seguir facilitando el acceso al tratamiento, aún en una situación de crisis económica y mejorar la adherencia. La adherencia terapéutica es clave y se correlaciona con el éxito del tratamiento en todos los estudios.