Health at a Glance: Europe 2018 - State of Health in the EU Cycle - CHARTSET

Health at a Glance:
Europe 2018
-
State of Health
in the EU Cycle
Joint publication of the OECD
and the European Commission
Released on November 22, 2018
http://www.oecd.org/health/health-at-a-glance-europe-23056088.htm

Table of Contents
1. Promoting mental health in Europe: Why and how?
2. Strategies to reduce wasteful spending: Turning the
lens to hospitals and pharmaceuticals
3. Health status
4. Risk factors
5. Health expenditure and financing
6. Effectiveness: Quality of care and patient experience
7. Accessibility: Affordability, availability and use of
services
8. Resilience: Innovation, efficiency and fiscal
sustainability
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 the 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 Union: 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.

• Costs of mental health problems
• Actions to promote mental health and
prevent mental illness
1. PROMOTING MENTAL HEALTH
IN EUROPE: WHY AND HOW?
Note: The definition of mental health draws on the WHO definition of mental health as a state of well-being in
which the individual realises his or her own abilities, can cope with the normal stresses of life, can work
productively, and is able to make a contribution to his or her community. On the other hand, mental health
problems are defined as the loss of mental health due to a mental illness or disorder.

The total costs of mental health problems are more than 4%
of GDP across EU countries, ranging from 2% to 5%
Source: OECD estimates based on Eurostat Database and other data sources.
Estimated direct and indirect costs related to mental health problems across EU countries, as a % of GDP, 2015

More than one in six people in EU countries
have a mental health problem in any given year
Source: IHME, 2018 (these estimates refer to 2016).
18.8%
18.6%
18.5%
18.5%
18.4%
18.3%
18.3%
18.3%
18.0%
17.9%
17.9%
17.7%
17.7%
17.7%
17.6%
17.3%
17.3%
17.0%
17.0%
16.9%
16.9%
15.7%
15.5%
15.4%
15.2%
15.1%
14.9%
14.8%
14.3%
18.5%
17.5%
16.7%
0%
5%
10%
15%
20%
25%
Anxiety disorders Depressive disorders Alcohol and drug use disorders
Bipolar disorders and schizophrenia Others

People reporting chronic depression are much
less likely to work in all EU countries…
Note: Due to missing data, the assumption has been made that the situation in Ireland is the same as the EU average.
Source: Eurostat Database, based on the European Health Interview Survey (2014).
0
10
20
30
40
50
60
70
80
90
100
% of working age pop. aged 25-64 With depression Without depression
% of working age population aged 25-64
Employment rate of people aged 25 to 64 years old
…and when they work, people with depression or other
mental health problems are often less productive
 about 6% less productive

Actions to promote mental health are uneven across the life course:
fewer programmes target the unemployed and older people
Source: McDaid, Hewlett and Park (2017); EU Compass for Action on Mental Health and Wellbeing (2017); WHO
(2018); EU Compass for Action on Mental Health and Wellbeing, 2018 (2018).
Number of countries reporting at least one promotion or prevention action, out of the 31 EU and EFTA countries
0
5
10
15
20
25
Pre-natal period to age 2 Children aged 2-10 Young people aged 11-25 Workplace mental health Mental health of the
unemployed
Older people
Number of countries reporting at least one action

• Addressing wasteful spending in hospitals
• Addressing wasteful spending on pharmaceuticals
2. STRATEGIES TO REDUCE
WASTEFUL SPENDING
Note: Wasteful spending includes patients who receive unnecessary or low-value care that makes little or no
difference to their health outcomes or for whom the same health benefits could be obtained with fewer
resources.

Strategies to reduce hospital costs
Increase efficiency
and safety to
reduce the use of
hospital resources
Reduce
unnecessary
hospital
admissions
Ensure patients
leave hospital as
early as possible
Improve community care for
chronic diseases
Tackle hospital
services overuse
Deploy
day surgery
Curb delayed
discharges

Potentially avoidable hospital admissions for chronic
conditions consume over 37 million bed days each year
Source: OECD Health Statistics and Eurostat Database.
Diabetes Hypertension
Heart
failure
COPD &
bronchiectasis
Asthma
Total (five
conditions)
Admissions/discharges 800 303 665 396 1 749 384 1 109 865 328 976 4 653 924
% of all admissions 1.0% 0.8% 2.1% 1.3% 0.4% 5.6%
Average length of stay
(days)
8.5 6.9 9.5 8.9 6.6 8.1 (avg.)
Total bed days 6 794 572 4 597 886 16 619 148 9 855 601 2 177 821 37 603 706
Proportion of all bed days 1.1% 0.7% 2.7% 1.6% 0.4% 6.5%
Hospital admissions and bed days for five chronic conditions, EU countries, 2015

C-section rates are much higher than the EU average in Romania,
Bulgaria, Poland and Hungary, and have increased over time
Note: The annual growth rate for Luxembourg only covers the period 2011 to 2016 due to a break in the series in 2011.
Source: Eurostat, except Netherlands: Perinatal registry (www.perined.nl/).
Netherlands
Finland
Sweden
Lithuania
Estonia
Denmark
Slovenia
France
Belgium
Latvia
Croatia
Spain
Czech
Republic
UK
EU
Average
Austria
Slovak
Republic
Germany
Malta
Luxembourg
Ireland
Portugal
Italy
Hungary
Poland
Bulgaria
Romania
-2%
-1%
0%
1%
2%
3%
4%
5%
6%
7%
8%
100 150 200 250 300 350 400 450
Number of C-sections per 1 000 live births
AverageannualgrowthrateofC-sections,past10years
C-section rates in 2016 and their annual growth rate between 2006 and 2016

Several countries are lagging behind in exploiting
the potential cost-saving of generic medicines
0
10
20
30
40
50
60
70
80
90
Volume Value
%
Generic market share by volume and value, 2016 (or latest year)
Source: OECD Health Statistics 2018.

Reducing the over-prescription of antibiotics and
other medicines can also help reduce waste
Note: Cyprus and Romania provide data on overall consumption, including in hospital.
Source: European Centre for Disease Prevention and Control (ECDC) (2017).
Consumption of antibiotics in the community, EU/EEA countries, 2016 (DDDs per 1 000 population per day)

• Trends and inequalities in life expectancy
• Inequalities in self-reported health
3. HEALTH STATUS

Life expectancy exceeds 81 years in a majority of EU countries, but
the gap between the highest and lowest countries is still over 8 years
1. Three-year average (2014-16).
Source: Eurostat Database.
83.5
83.4
82.7
82.5
82.4
82.3
82.2
81.8
81.8
81.7
81.5
81.5
81.5
81.3
81.2
81.2
81.0
81.0
80.9
79.1
78.2
78.0
78.0
77.3
76.2
75.3
74.9
74.9
74.9
83.7
82.5
82.5
78.5
78.1
76.5
75.7
75.4
60
65
70
75
80
85
90
Years
Total Women Men
Life expectancy at birth, by gender, 2016

Gains in life expectancy have slowed down
in many Western European countries since 2011,
with reductions registered in 2015
Trends in life expectancy, 2005-16
75
77
79
81
83
85
2005 2007 2009 2011 2013 2015
Years
Life expectancy at birth
10
11
12
13
14
15
2005 2007 2009 2011 2013 2015
Years
Life expectancy at 75
EU28 Germany France Italy United Kingdom

Note: Data refer to 2012 for France and Austria and to 2011 for Latvia, Belgium and the United Kingdom (England).
Source: Eurostat Database; national sources or OECD calculations using national data for Austria, Belgium, France,
Latvia, the Netherlands and the United Kingdom (England).
There are large gaps in life expectancy by education level:
people with low education at age 30 can expect to live six years less than
the most educated (eight years for men, four years for women)
Slovak Republic
Hungary
Poland
Czech Republic
Latvia
Romania
Estonia
EU21
Bulgaria
France
Slovenia
Austria
Greece
Netherlands
Belgium
Finland
Denmark
Portugal
Croatia
Italy
United Kingdom
Sweden
Norway
Women Men
6.9
6.4
5.1
3.0
8.0
3.8
5.4
4.1
4.5
2.6
2.8
3.0
2.4
4.6
4.4
3.5
3.9
2.8
1.6
2.9
4.0
2.9
3.4
05101520
Years
14.4
12.6
12.0
11.1
11.0
9.7
8.5
7.7
6.9
6.5
6.2
6.2
6.0
5.8
5.8
5.6
5.6
5.6
5.2
4.5
4.4
4.1
5.0
0 5 10 15 20
Years
Gap in life expectancy at age 30 between people with the lowest and highest level of education,
2016 (or nearest year)

Source: Eurostat Database, based on EU-SILC.
There are also large gaps in self-reported health by income level:
60% of people with the lowest income report being in good health
compared with 80% for those with the highest income
83 79 76 75 74 74 73 73 71 71 71 70 70 69 69 68 67 66 66 65 65 60 60 59 59 53 48 47 43 78 78 77 76 70 57
0
10
20
30
40
50
60
70
80
90
100
% of population aged 16 years and over
Total population Low income High income
Health status perceived as good or very good, by income quintile, 2016 (or nearest year)

• Smoking
• Alcohol consumption
• Overweight and obesity
• Air pollution
4. RISK FACTORS

Source: OECD Health Statistics 2018 (based on national health interview surveys), complemented with Eurostat
(EHIS 2014) for Bulgaria, Croatia, Cyprus, Malta, and Romania, and with WHO Europe Health for All database
for Albania, Serbia and Montenegro.
Changes in daily smoking rates among adults, 2006 and 2016 (or latest year)
Smoking among adults has declined across EU
countries, but still one-fifth of adults smoke daily
28 27
26 26 25 25 24 23 23 23 22 21 21 20 20 20 20 20 20 19 19 18 18 17 17 16 16 15
11
38
31
29
27
18
11 10
0
5
10
15
20
25
30
35
40
45
2006 2016
% reporting to smoke daily

The proportion of adolescents reporting “binge drinking” has come
down slightly in recent years, but still nearly 40% report regular
“binge drinking” on average across the EU
Note: “Binge drinking” is defined as drinking five or more alcoholic drinks in a single occasion. The EU average is not
weighted by country population size.
Source: ESPAD.
0
10
20
30
40
50
60
1995 1999 2003 2007 2011 2015
%
Boys
Girls
Boys Girls
%
Changes between 1995 and 2015 in the proportion of 15-16 year old boys and girls reporting heavy episodic
drinking in the past 30 days, average across EU countries and Norway

Obesity among adults is rising:
one in six adults are obese across EU countries
Source: Eurostat (EHIS 2008 and 2014) complemented with OECD Health Statistics 2018 for 2000 data and data
for non-EU countries.
25
21
20 20 19 19 19 18 18 18
17 17 17 17 17 16 16 16 16 15 15 15 14 14 14 13
12
10 9
20 19
12
10
0
5
10
15
20
25
30
2000 2008 2014
%
Changes in self-reported obesity rates among adults, 2000 to 2014 (or nearest year)

Exposure to serious air pollution is estimated to have caused the
death of 238 000 people across EU countries in 2016; mortality rates
are highest in Central and Eastern Europe
Source: IHME (Global Burden of Disease, 2016).
Deaths due to exposure to outdoor PM2.5 and ozone, 2016

• Health expenditure per capita and as a
share of GDP
• Financing mix (government schemes, out-
of-pocket and voluntary health insurance)
5. HEALTH EXPENDITURE AND
FINANCING

Source: OECD Health Statistics 2018; Eurostat Database; WHO Global Health Expenditure Database.
Health spending per capita is highest in Luxembourg, Germany and
Sweden, and lowest in Romania, Bulgaria and Latvia
Health expenditure per capita, 2017 (or nearest year)
4713
4160
4019
3945
3930
3885
3831
3572
3493
3045
3013
2773
2568
2551
2446
2066
2023
1873
1722
1678
1625
1551
1473
1463
1409
1367
1252
1234
983
5799
4653
3309
987
824
728
638
583
0
1000
2000
3000
4000
5000
6000
7000
EUR PPP

Health spending accounts for nearly 10% of GDP in the EU; France and
Germany allocate more than 11% of their GDP to health spending
Health expenditure as a share of GDP, 2017 (or nearest year)
11.5
11.3
10.9
10.3
10.2
10.1
10.0
9.6
9.6
9.2
9.0
8.9
8.9
8.8
8.4
8.4
8.0
7.5
7.2
7.1
7.1
7.1
6.8
6.7
6.7
6.3
6.3
6.1
5.2
12.3
10.4
9.4
8.5
6.8
6.1
5.9
4.2
0
2
4
6
8
10
12
14
% GDP

Health expenditure has grown in line with GDP growth in recent years,
so the share of GDP allocated to health has stabilised
Source: OECD Health Statistics 2018; Eurostat Database.
Source : OECD Health Statistics 2018; Eurostat Database. Source : OECD Health Statistics 2018; Eurostat Database.
-5
-4
-3
-2
-1
0
1
2
3
4
5
2005 2007 2009 2011 2013 2015 2017
%
5.4. Annual average growth (real terms) in per capita
health expenditure and GDP, EU28, 2005 to 2017
Health expenditure GDP
6
7
8
9
10
11
12
2005 2007 2009 2011 2013 2015 2017
% GDP
5.5. Health expenditure as a share of GDP, EU28 and
selected countries, 2005 to 2017
France Germany Italy
Spain EU28
Annual average growth (real terms) in per capita
health expenditure and GDP,
EU28, 2005 to 2017
Health expenditure as a share of GDP,
EU28 and selected countries, 2005 to 2017

Note: Countries are ranked by government schemes and compulsory health insurance as a share of health expenditure.
Over 75% of health spending is financed through government and
compulsory insurance across EU countries. Out-of-pocket payments
account for 18%, but represent a much greater share in some countries
Health expenditure by type of financing, 2016 (or nearest year)
7
84 84
5
12
6 9 4
79
18
13
2
36
11
62
74
30
4
72
66
10 10
65
8
63
31
55
9
42
74
82
23
1 6
21
4
9
78 78
70
75 72 76
61
65
75
41
65
13
44
69
5
60 57 58
30
41
11
56
66 58
42
55
34
12 14 15
10 15
11 11
18
15 16 21
15 18 23
20 23
19
12 13
24 23 32
28 30 35 34 45 48
45
15
17
16
32 36
30 41
57
7 6 5 3 5 8 4 5
14 12
5 5 5 4
6
76 5
0
10
20
30
40
50
60
70
80
90
100
%
Government schemes Compulsory health insurance Out-of-pocket
Voluntary health insurance Other

• Avoidable mortality (preventable and
amenable)
• Vaccination
• Patient experience with ambulatory care
• Acute care for cancers and heart attacks
6. EFFECTIVENESS: QUALITY OF
CARE & PATIENT EXPERIENCE

Note: Preventable mortality is defined as deaths that could be avoided through public health and prevention interventions, whereas
amenable (or treatable) mortality is defined as deaths that could be avoided through effective and timely health care. A number of causes
of death are included in both preventable and amenable mortality resulting in double-counting; this explains why the total number of
avoidable deaths is lower than the sum of the two parts.
More than 1.2 million deaths could be avoided through better public
health and prevention policies and more effective and timely health care
Leading causes of preventable and amenable mortality in the European Union, 2015
Amenable mortality
(570 791 deaths in 2015)
Preventable mortality
(1 003 027 deaths in 2015)
Hypertension,
5%
Colorectal
cancer, 12%
Breast cancer,
9%
Hypertension,
5%
Ischaemic heart
diseases, 32%
Cerebrovascular
diseases, 16%
Influenza and
pneumonia, 5%
Others, 22%
Colorectal
cancer, 7%
Lung cancer,
17%
Alcohol, 7%
Ischaemic heart
diseases, 18%
Accidents, 16%
Suicide, 7%
Others, 29%

Source: WHO/UNICEF.
Many children are not vaccinated against
infectious diseases in several countries
Vaccination against measles and hepatitis B, children aged 1, 2017 (or nearest year)
Note: Hepatitis B data for Denmark, Finland, Hungary, Iceland
and Norway are not available because national infant
vaccination programmes do not cover Hepatitis B. Data is not
available for the United Kingdom.

Over 85% of patients report positive experiences
with doctors in ambulatory care in most countries
1. National sources. 2. Data refer to patient experiences with GP.
Note: 95% confidence intervals have been calculated for all countries, represented by grey areas.
Source: Commonwealth Fund International Health Policy Survey 2016 and other national sources.
Doctor spending enough time
with patient in consultation,
2010 and 2016 (or nearest year)
Doctor involving patient
in decisions about care and treatment,
2010 and 2016 (or nearest year)

In terms of acute care, fewer people are dying
following acute myocardial infarction (heart attack)
Thirty-day mortality after admission to hospital for AMI (based on unlinked data), 2005 and 2015 (or nearest years)
1. Three-year average.
Note: 95% confidence intervals for the latest year are represented by grey areas. The EU average is unweighted and only
includes countries with data covering the whole time period.

• Unmet health care needs
• Financial protection
• Supply of doctors
• Timely access (waiting times)
7. ACCESSIBILITY: AFFORDABILITY,
AVAILABILITY AND USE OF SERVICES

Source: Eurostat Database, based on EU-SILC.
Poor people are more likely to report unmet needs for medical care,
and even more so for dental care
Unmet need for medical examination
for financial, geographic or waiting times reasons,
by income quintile, 2016 (or nearest year)
Unmet need for dental examination
for financial, geographic or waiting times reasons,
by income quintile, 2016 (or nearest year)
Estonia
Greece
Latvia
Poland
Romania
Italy
Finland
Lithuania
Bulgaria
Ireland
EU28
Belgium
Portugal
Slovak Republic
Croatia
Sweden
France
Hungary
Denmark
Malta
United Kingdom
Czech Republic
Cyprus
Spain
Luxembourg
Slovenia
Germany
Netherlands
Austria
Montenegro
Turkey
Serbia
Iceland
FYR of Macedonia
Norway
Switzerland
0 10 20 30
%
High income Low incomeTotal population
Portugal
Greece
Latvia
Estonia
Italy
Romania
Finland
Spain
Lithuania
EU28
Belgium
Denmark
Poland
Cyprus
Sweden
Bulgaria
Ireland
France
Slovak Republic
Hungary
United Kingdom
Croatia
Malta
Luxembourg
Czech Republic
Slovenia
Germany
Austria
Netherlands
Iceland
Serbia
Montenegro
Turkey
Norway
Switzerland
FYR of Macedonia
0 10 20 30
%
High income Low incomeTotal population

Direct out-of-pocket spending by households
can restrict access to care
48
45 45
35 34
32
30
28
24 23 23 23
21 20
19 18 18
16 15 15 15 15 14 13 12 12 11 11
10
57
41
36
32
30
17 16
15
0
10
20
30
40
50
60
%
Share of total health spending financed by out-of-pocket payments, 2016 (or latest year)

1. Data refer to all doctors licensed to practice, resulting in a large over-estimation of the number of practising doctors (e.g.
of around 30% in Portugal).
2. 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).
The number of doctors per capita has increased
in nearly all EU countries since 2000…
Practising doctors per 1 000 population, 2000 and 2016 (or nearest year)
6.6
5.1
4.8
4.5 4.3 4.2 4.1 4.0 3.8 3.8 3.8 3.7 3.7 3.6 3.5 3.5 3.5
3.2 3.2 3.2 3.2 3.1 3.1 3.0 2.9 2.9 2.8 2.8
2.4
4.5
4.3
3.9
3.0 3.0
2.6
1.8
0
1
2
3
4
5
6
7
2000 2016
Per 1 000 population

…but general practitioners (family doctors) make
up less than 25% of all doctors on average
Share of different categories of doctors, 2016 (or nearest year)
1. Other generalists include non-specialist doctors working in hospital and recent medical graduates who have not started yet
their post-graduate specialty training.
2. In Portugal, only about 30% of doctors employed by the public sector (NHS) are working as GPs in primary care, with the
other 70% working in hospital.
46
38 37 37
30 27 24 24 24 23 22 22 21 21 20 20 19 19 18 17 17 15 15 15 9 5
33 32 27 24 18 17 16
0
20
40
60
80
100
%
General practitioners Other generalists¹ Specialists Other doctors (not further defined)

Note: On the right panel, data relate to median waiting times, except for the Netherlands and Spain (average waiting times).
Waiting times for hip replacement vary widely across countries, and
has started to rise again in some countries since 2010
Waiting times of patients for hip replacement, 2016 and trends since 2005
n.a.
37
51
75
84
90
64
105
130
211
276
110
45
52
80
82
104
104
120
133
158
326
444
134
0
100
200
300
400
500
Days
Median Average
0
50
100
150
200
250
Days
Denmark Estonia
Netherlands Portugal
Spain United Kingdom

• eHealth and ePrescription
• Hospital efficiency
• Fiscal sustainability of public spending on
health and long-term care
8. RESILIENCE: INNOVATION,
EFFICIENCY AND FISCAL
SUSTAINABILITY

Note: Greece and the Netherlands are implementing ePrescribing but the percentage was not reported.
Source: Pharmaceutical Group of the European Union (PGEU).
ePresribing is now widely used in Nordic countries and some Southern
European countries, but hasn’t been implemented yet in several countries
Percentage of ePrescriptions in community pharmacies, 2018

1. Data refer to average length of stay for curative (acute) care only (resulting in an under-estimation).
In hospital, the average length of stay of patients has fallen
in nearly all EU countries, reflecting efficiency gains
Average length of stay in hospital, 2000 and 2016 (or nearest year)
10.1
9.5
9.3 9.1 9.0 8.9 8.8 8.5 8.3 8.2 7.9 7.9
7.8
7.7 7.7 7.5 7.5 7.4 7.3 7.1 7.1 7.0 6.8
6.0 6.0 5.8
5.4 5.3 5.0
10.2
8.8
8.3
6.9
6.2
5.8
4.0
2
4
6
8
10
12
14
2000 2016
Days

Source: EC and EPC (2018).
Public spending on health care as a share of GDP is projected
to grow in all countries over the coming decades
Public spending on health care as a percentage of GDP, 2016 to 2070,
Ageing Working Group reference scenario
0
1
2
3
4
5
6
7
8
9
10
% GDP
2016 Change 2016-70

Public spending on long-term care as a share of GDP is projected to
grow even more than health care due to population ageing
Public spending on long-term care as a percentage of GDP, 2016 to 2070,
Ageing Working Group reference scenario
Source: EC and EPC (2018).
0
1
2
3
4
5
6
7
8
% GDP
2016 Change 2016-70

More information
http://www.oecd.org/health/health-at-a-glance-europe-23056088.htm
https://ec.europa.eu/health/state/glance_en

Health at a Glance: Europe 2018 - State of Health in the EU Cycle - CHARTSET

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